a patient’s guide to cryosurgery for prostate...

A Patient’s Guide toCryosurgery forProstate Cancer

A Patient’s Guide toCryosurgery forProstate Cancer

Mr John Davies BSc FRCS(Urol)Mr Christopher Eden MS FRCS(Urol)Professor Stephen Langley MS FRCS(Urol)

Prostate Cancer Centre, Guildford

This booklet is intended to help you understand your prostate and what your operation will involve

This is a booklet for men who are either considering treatment, or arebeing treated, for prostate cancer by cryosurgery. It also provides usefuladvice and information for their families. It is best read in conjunctionwith the more general booklet in this series, A Patient’s Guide to ProstateCancer, which provides an overview of the subject and introducesterms used in this booklet. This booklet may have already been givento you, or it may be viewed and downloaded from the website:www.prostatecancercentre.com

© 2005 ISBN: 1 898763 16

This book is copyright under the Berne Convention.No reproduction without permission. All rights reserved.

First published in 2005

Written by:

Mr John Davies*, Mr Christopher Eden and Professor Stephen LangleyThe Prostate Cancer CentreStirling Road, Guildford, Surrey GU2 7RF

www.prostatecancercentre.comTel: 0845 370 7000 (local rate)

*John Davies has pioneered cryosurgical treatment for prostate cancer in the

United Kingdom

ContentsIntroduction 1

How Cryosurgery Works 2

Cryosurgery 3Patient Selection 4

Advantages of Cryosurgical Treatment 5

Disadvantages of Cryosurgical Treatment 6

Pre-Operation 7Post-Operation 8

Complications and Side-Effects 9

Impotence 9

Post-Cryosurgery and Removal of Catheter 10Pelvic Floor Exercises 10

Summary 11Commonly Asked Questions 12

Useful Website Addresses and Support Networks 13

Introduction

A Patient’s Guide to Cryosurgery for Prostate Cancer 1

Cryosurgery is a technique designed to destroy theprostate gland in a minimally invasive manner (i.e.there is no need for incisions), utilising cryogenicgas. It can be used for men with prostate cancerconfined to the gland and also in men where theprostate cancer is locally advanced (i.e. the cancer

Prostategland

Urethra

Anus

Rectum

Seminalvesicle

Testis

Pelvicfloor

External urinarysphincter muscle

Bladder

Diagram ofthe prostatearea (sideview).

A Patient’s Guide to Cryosurgery for Prostate Cancer2

has spread to the outer edge of the gland). In theUnited Kingdom, it is mainly used for men who haverecurrent prostate cancer following radiotherapytreatment (this also includes brachytherapy, aprocedure whereby small radioactive seeds areimplanted into the prostate). For more informationon either radiotherapy or brachytherapy, please readA Patient’s Guide to External Beam Radiotherapy andA Patient’s Guide to Prostate Brachytherapy,respectively, which should be available at yourhospital or may be viewed and downloaded fromthe internet at www.prostatecancercentre.com

How cryosurgery works

D: After warming, ice has melted, leavingonly dead cells

C: Ice continues to form and destroys cellstructures

B: Ice crystals beginning to form inside cellsA: Cells before treatment


Cryosurgery is also referred to as cryoablation orcryotherapy. It is a technique that involves using acarefully controlled freezing process as the surgery,instead of a scalpel. Cryogenic gases are circulatedthrough tiny cryoprobes or needles within theprostate, which are introduced through the skin.

The concept of using extreme cold to treat prostatecancer was developed in the 1960s, when liquidnitrogen was used to freeze the prostate in a ratherunsophisticated manner, but its use was limited byhigh complication rates and unsatisfactory results.

However, the introduction of liquid argon andhelium gas technology, linked to sophisticated andaccurate prostate ultrasound scanning techniques,has allowed cryosurgery to develop, using aprocedure that minimises complications andimproves results.

During the process, the prostate is frozen to -140°Cby argon gas, then warmed, using helium gas. Finecryoneedles are introduced through the perineum,the area between the scrotum and anus, underultrasound control and using a template for accuracy.

Cryosurgery

Although minimally invasive, it is a procedure thatrequires expertise in prostatic ultrasound scanning,cryoneedle placement and experience inmonitoring ice-ball formation.


Cryoneedles attached tocryotherapy machine.

Cryosurgery is most commonly used for men withprostate cancer that has recurred after radiotherapytreatment (including brachytherapy) when it remainsconfined to the prostate gland. It has also been usedto treat patients with locally advanced disease.

Patient selection

There are no incisions.Temperature needles are usedto monitor the process precisely, particularly aroundthe sphincter muscle, which is situated below theprostate, and also the wall of the rectum. A warmingcatheter is used throughout the procedure, to protectthe inner lining of the urethra and sphincter musclearea.


Cryosurgery is best used in situations where the PSAis less than 15 and the Gleason grade of thepathology is grade 7 or below.

Men who have severe urinary symptoms, or thosewho have had previous prostatic surgery may notbe suitable, although this will be assessed at theinitial consultation by a questionnaire and urinaryflow tests. A preliminary telescope examination,under local anaesthetic, and bladder pressuremonitoring, also under local anaesthetic, may benecessary as part of the initial assessment.

Some men may have a large prostate gland, whichcan make cryosurgery difficult. It is usually possible toshrink the gland, using hormonal agents which areoften used in prostate cancer treatment.This isdiscussed at the initial consultation if necessary.

Cryosurgery is minimally invasive and can be carriedout either as a day-patient case or with an overnightstay. There is little in the way of post-operative pain,although bruising is quite common around the siteof the cryoneedles in the perineal area.

Most men are up and about quickly following theprocedure, although it is advisable not to takestrenuous exercise during the period whilst thecatheter is in place.

There is usually no need for a transfusion, as blood

Advantages of cryosurgicaltreatment


loss is minimal. Cryosurgery can be repeated at alater stage if necessary.

Cryosurgery can be used for men who have arecurrence of prostate cancer post-radiotherapy(including brachytherapy). It can also be used inmen who are unsuitable for major surgery orradiotherapy.

Focal cryosurgery, a procedure in which the tumourwithin the gland is identified and treated, has beenintroduced in some centres, particularly in theUnited States. The technique is still under review,although early results are promising, especially withregard to lower impotence rates.

The technique has a higher risk of impotence thanother treatments, as the nerves involved in creatingan erection lie just behind theprostate gland, adjacent tothe rectum, and areincluded in the freezeprocess. However,recovery can occurover 12 months or so.Patients can beinstructed in the use ofmedications such asViagra, injection therapyand vacuum erectiondevices, if necessary.

Figure showingclose proximityof the prostategland anderectile nerves.

Prostate gland Nerves associatedwith creatingerections

Disadvantages of cryosurgicaltreatment


Pre-Operation

On admission to hospital, the procedure isdiscussed both with the surgeon and with theanaesthetist. The procedure can be carried outunder either a general or a local anaesthetic (i.e.spinal). Patients are usually given a simple enema toclear the lower bowel.

The procedure takes between 1-2 hours.Intravenous antibiotics are given to guard againstthe risk of infection.

Cryoneedles are introduced through the perineumunder ultrasound guidance and a computer

Transrectalultrasound

Prostategland

Cryoneedle

Argon/heliumgas supply

Cryosurgicaltechnique.1: Placement ofcryoneedlesunderultrasoundguidance.


Post-Operation

When the patient awakes, he will have a urethralcatheter draining through his penis. This allowsswelling of the prostate to settle down in the 14days or so following the cryosurgery. There will bedressings around the perineum, to minimisebruising. The patient is returned to the ward andlater instructed on how to use the catheter. Thepatient is discharged with dressings, which arechanged daily following a bath. Simple painkillersmay be necessary to relieve discomfort, althoughthis is usually quite minimal.

technique, utilising a template grid. Full temperaturemonitoring is carried out and the urethra is warmedto preserve the sphincter muscle.

Ice balldeveloping inprostate gland

Cryosurgicaltechnique.2: Destructionof prostatetissue by iceformation.


This is a common problem following cryosurgicaltreatment and will have been discussed in detail

before consideration of cryosurgery. Recoveryis possible over twelve months or so. There

are various ways of helping with thisproblem and these are usually discussedbefore the operation with the surgery and

cryosurgery nurse specialist.

● Constipation is quite common following anysurgical procedure and is usually managed bysimple means such as gentle laxatives andincreased fluid intake.

● Bruising of the perineal area is common and ismanaged by simple dressings and avoidingprolonged periods of standing in the two weeksfollowing cryosurgery.

● Blood in the urine is very common followingcatheter insertion and removal and can occurintermittently for several weeks after cryosurgery.

● Longer term problems can include urinaryincontinence, particularly during coughing andsneezing (stress incontinence).

● Very rarely, damage can occur to the rectum(fistula). This complication may need furthersurgery to resolve.

● Patients are discharged following catheterremoval, with simple pads to minimise discomfortand are given full instructions in pelvic floorexercises (see page 10).

Complications and side-effects

Impotence


● To do these exercises effectively, you need to firstrelax your abdominal and buttock muscles.

● To identify and correctly contract the pelvic floormuscles, imagine that you are trying to hold backbowel movements or from passing gas.

● During this action, you should feel the opening ofthe rectum contract.

Pelvic floor exercises

Bladder

Rectum

Testis

Pelvicfloor

External urinarysphincter muscle

Location ofthe pelvicfloor.

Men can return to normal activities followingcatheter removal. It is advisable to continue withthe pelvic floor exercises (see below).

Post-Cryosurgery andRemoval of Catheter


● Tighten the muscles for 3-5 seconds and thenrelax for 6-10 seconds. Repeat this sequence 20-25times.

● Do the set of 20-25 contractions 3-4 times daily.

● During the first week of the programme, performthe exercises whilst lying down, but later whilesitting and standing. After the initial learningperiod, perform the exercises when you needthem, i.e. just before sneezing, coughing or straining.

SummaryCryosurgery is an effective treatment for men whohave evidence of recurrence of prostate cancerfollowing treatment utilising external beamradiotherapy or brachytherapy and has beenreviewed and approved by the National Institute ofClinical Excellence (NICE). However, staginginvestigations are essential to check that the diseaseremains confined to the prostate gland.

Cryosurgery is a technique requiring considerable skillin ultrasound scanning of the prostate and needleplacement. In addition, as with all surgical techniques,the best results are obtained by surgeons who havecarried out a large number of these procedures.Thisshould be discussed with the surgeon before makinga final decision with regard to treatment.


Commonly Asked Questions(taken from The Prostate Cancer Charity Toolkit)

● Will I be given hormone treatment prior to thecryosurgery? If yes, why? If not, why not?

● How long does the operation take?

● Will I have a blood transfusion?

● How many of these operations do you do a year?

● Will you be targeting any organ other than myprostate?

● Will you attempt to do nerve-sparing cryosurgeryif possible? In your experience, how successful isthis procedure?

● What are your results in respect of impotence andincontinence?

● How long will I be in hospital?

● Will I have much pain after cryosurgery and howwill it be controlled?

● If I go home with a catheter, when will it beremoved and by whom?

● How soon is my follow-up appointment afterdischarge?

● If I have continence problems after thecryosurgery, how would these be managed andby whom?

● How often will my PSA be checked?

● What should the PSA be after cryosurgery? Whatwould it mean if it doesn't reach that level? Whatwould you do then?


The Continence Foundation www.continence-foundation.org.uk‘For people with bladder and bowel problems.’

The Prostate Cancer Centre www.prostatecancercentre.com‘Providing a single point of referral to specialists at the forefront of the treatment of localisedprostate cancer.’Mr John Davies - Cryotherapy and high intensity focused ultrasound (HIFU).Mr Christopher Eden - Laparoscopic radical prostatectomy.Professor Stephen Langley - Brachytherapy.

The Prostate Cancer Charity www.prostate-cancer.org.uk‘Prostate cancer is our sole concern.’

The Sexual Dysfunction Association www.impotence.org.uk‘To help sufferers of impotence (erectile dysfunction) and their partners.’

The Prostate Project www.prostateproject.org‘A local charity promoting male health.’

Useful website addresses and support networks

Published by:

Eurocommunica Limited

Caxton House, 51 Barnham Road, Barnham, West Sussex PO22 0ER

The views and opinions contained in this book are those of the authors and not necessarily those of Eurocommunica Limited.

Useful Telephone NumbersFor administrative matters, treatment dates or enquiries, during office hours, please contact:

NHS Patients Private PatientsMedical Secretary to Mr John Davies Private Secretary to Mr John DaviesRoyal Surrey County Hospital Mount Alvernia HospitalTelephone: 01483 571122 Ext: 4878 Telephone: 01483 567517

Fax: 01483 455488E-mail: [email protected] E-mail: [email protected]

For enquiries relating to patient care or problems, during office hours, please contact:

Cryotherapy Nurse Specialist Cryotherapy FellowRoyal Surrey County Hospital Royal Surrey County HospitalTelephone: 01483 571122 Telephone: 01483 571122Pager: 0766 (via hospital switchboard) Pager: 4841 (via hospital switchboard)

For enquiries relating to patient care or problems, at other times, please contact the wardbelow or discuss with your GP:

NHS Patients Private PatientsFrensham Ward Surgical WardRoyal Surrey County Hospital Mount Alvernia HospitalTelephone: 01483 406858 Telephone: 01483 570122

Hospital AddressesNHS Patients Private PatientsRoyal Surrey County Hospital Mount Alvernia HospitalEgerton Road, Guildford Harvey Road, GuildfordSurrey GU2 5XX Surrey GU1 3LX

Date of preparation: July 2005

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