Prostate Cancer: TURP, HIFU, Cryotherapy and Focal Therapy
Guidelines and review literature: (EAU Guidelines, Mottet et al, 2015) (S3-Leitlinie Prostatakarzinom der DGU) (Walsh-Campbell Urology 11th Edition).
Palliative TURP for Prostate carcinoma
Indication for Palliative TURP
Palliative transurethral resection of the prostate (TURP) is indicated for subvesical obstruction and urinary retention, if radical prostatectomy is not an option.
Outcome of Palliative TURP
Cure of prostate carcinoma with TURP is not possible. Compared to TURP for BPH, complications are more frequent. This includes a higher rate of urinary incontinence, postoperative urinary retention, bleeding, and recurrence of obstruction. In order to avoid incontinence, a limited resection is often performed.
Experimental Local and Focal Therapy of Prostate Cancer
High-Intensity Focused Ultrasound (HIFU) of the Prostate:
High-intensity focused ultrasound (HIFU) destroys the prostate tissue via a transrectal ultrasound probe. HIFU leads to tissue necrosis, which is gradually degraded by the immune system. Available data is limited to retrospective series with maximum follow-up of 14 years. In summary, the oncological results are dependent on known risk factors and comparable to radiotherapy: the 10-year survival is 88% (low risk), 82% (medium risk) and 48% (high risk) using the D'Amico classification of prostate cancer risk (Blana et al, 2004) (Ganzer et al, 2013). Side effects of HIFU include erectile dysfunction (44-61%), urinary incontinence (0-14%) and persistent subvesical obstruction (up to 30%), which however can be treated with neoadjuvant or adjuvant TURP. Rare severe complications such as rectal fistulae have been reported (0.7–3.2%) (Pickles et al, 2005).
Cryotherapy of Prostate Cancer:
Cryotherapy is experiencing a renaissance through several technical innovations. Modern cryotherapy devices can apply the freezing and thawing cycles with high speed and high accuracy, the iceball formation can be accurately observed by modern transrectal ultrasound probes (Touma et al, 2005). Complications can be prevented with the help of urethral and rectal warming and with temperature monitoring. Possible complications include persistent subvesical obstruction, urinary incontinence, erectile dysfunction, rectal fistulae and osteitis pubis with chronic pain.
Up to 8 cryoprobes are inserted into the prostate transperineally in Seldinger technique. A special catheter warms and protects the urethra. Under transrectal ultrasound imaging control of the ice ball formation, the prostate is freezed with minus 195 C, followed by rapid warming. Two freeze-thaw cycles are applied. The patient needs a urethral catheter for 1–3 weeks until the rejection of the necrotic tissue. Controlled studies or retrospective series with long follow-up are not available.
Focal Therapy of Prostate Cancer:
Clinically significant prostate cancer lesions can be visualized due to the advancement of imaging (see multiparametric MRI). If prostate cancer is limited to 1–2 lesions, focal therapy of these lesions is an option. In order to avoid side effects, treatment of the remaining prostata is omitted. Frequently, focal therapy is performed with HIFU (see above), but focal therapy is also possible with brachytherapy or cryotherapy. Focal therapy can be offered to patients that meet the criteria of active surveillance, but still want low-risk local therapy. Controlled studies or retrospective series with long follow-up are not available.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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- Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe,
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L. ; STEINHOFF, G.:
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