Dr. med. Dirk Manski

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Prostate Cancer: TURP, HIFU, Cryotherapy and Focal Therapy

Guidelines and review literature: (EAU Guidelines Prostate Cancer) (S3-Leitlinie Prostatakarzinom) (Walsh-Campbell Urology).

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.

Surgical technique:

See section TURP.

Outcome of Palliative TURP

Cure of prostate carcinoma with TURP is not possible. Compared to TURP for BPH, complications are more frequent, including a higher rate of urinary incontinence, postoperative urinary retention, bleeding, and recurrence of obstruction. To avoid incontinence, a limited resection is often performed.


Experimental Local and Focal Therapy of Prostate Cancer

Focal therapy:

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. The treatment of the remaining prostate is omitted to avoid side effects. Focal therapy is possible with VTP, HIFU, brachytherapy, or cryotherapy (see below). Focal therapy can be offered to patients who meet the criteria of active surveillance but still want low-risk local treatment. Follow-up after focal therapy, analogous to active surveillance, consists of regular imaging with mpMRI and prostate biopsies (targeted and systematic). If salvage therapy becomes necessary due to tumor progression, worse oncologic and functional outcomes may be possible due to the tissue effects of focal therapy.

Vascular-targeted photodynamic therapy (VTP):

After intravenous injection of padeliporfin (Tookad), a photosensitizing substance, transperineally introduced laser fibers are used to illuminate and thus destroy prostate tissue. The positioning of the optical fibers is accomplished with the aid of a template and planning software analogous to brachytherapy. The procedure requires anesthesia and hospitalization, but the short-term side effects are mild. Padeliporfin has been approved by the EMA since 2018. In the pivotal trial, focal therapy of the prostate was performed in patients with criteria for active surveillance. After 12 months, a negative control biopsy was seen in 48% (VTP) vs. 20% in patients with active surveillance (Azzouzi et al., 2017). After four years, conversion to active therapy was necessary in 24% vs. 53% (Gill et al., 2018).

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 a 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:

Perineal cryoprobes are positioned with TRUS in the prostate; additionally, thermosensor needles are used for temperature control. Modern cryotherapy devices can apply freezing and thawing cycles with high speed and high accuracy; ice ball formation in the prostate is easily visible with TRUS (Touma et al., 2005). Controlled comparative studies or retrospective series with long follow-ups are lacking regarding oncologic outcomes. Complications are prevented with 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.

Irreversible electroporation (IRE):

Via perineally inserted needle electrodes, a flowing current causes disruption of cell membranes and later tissue necrosis. The mild current application protects sensitive structures better than the above-mentioned thermal methods, and short-term side effects are mild. Controlled comparative studies or retrospective series with long follow-up are lacking regarding oncologic outcomes (Morozov et al., 2020).

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


EAU Guidelines EAU - EANM - ESTRO - ESUR - SIOG Guidelines on Prostate Cancer, https://uroweb.org/guidelines/prostate-cancer/.

Blana u.a. 2004 BLANA, A. ; WALTER, B. ; ROGENHOFER, et a.: High-intensity focused ultrasound for the treatment of localized prostate cancer: 5-year experience.
In: Urology
63 (2004), Nr. 2, S. 297–300.

Deger u.a. 2001 DEGER, S. ; BOHMER, D. ; ROIGAS, et a.: [Brachytherapy of local prostatic carcinoma].
In: Urologe A
40 (2001), Nr. 3, S. 181–4

Ganzer, R.; Fritsche, H.-M.; Brandtner, A.; Bründl, J.; Koch, D.; Wieland, W. F. & Blana, A. Fourteen-year oncological and functional outcomes of high-intensity focused ultrasound in localized prostate cancer.
2013, 112, 322-329.

Morris u.a. 2005 MORRIS, D. E. ; EMAMI, B. ; MAUCH, P. M. ; KONSKI, A. A. ; TAO, M. L. ; NG, A. K. ; KLEIN, E. A. ; MOHIDEEN, N. ; HURWITZ, M. D. ; FRAAS, B. A. ; ROACH, 3rd ; GORE, E. M. ; TEPPER, J. E.: Evidence-based review of three-dimensional conformal radiotherapy for localized prostate cancer: an ASTRO outcomes initiative.
In: Int J Radiat Oncol Biol Phys
62 (2005), Nr. 1, S. 3–19

Peinemann, F.; Grouven, U.; Bartel, C.; Sauerland, S.; Borchers, H.; Pinkawa, M.; Heidenreich, A. & Lange, S. Permanent interstitial low-dose-rate brachytherapy for patients with localized prostate cancer: a systematic review of randomised and nonrandomised controlled clinical trials.
Eur Urol, 2011, 60, 881-893.

Pickles u.a. 2005 PICKLES, T. ; GOLDENBERG, L. ; STEINHOFF, G.: Technology review: high-intensity focused ultrasound for prostate cancer.
In: Can J Urol
12 (2005), Nr. 2, S. 2593–7

Potters u.a. 2005 POTTERS, L. ; MORGENSTERN, C. ; CALUGARU, et a.: 12-year outcomes following permanent prostate brachytherapy in patients with clinically localized prostate cancer.
In: J Urol
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Leitlinienprogramm Onkologie (DGU, Deutsche Krebsgesellschaft, Deutsche Krebshilfe): Interdisziplinäre Leitlinie der Qualität S3 zur Früherkennung, Diagnose und Therapie der verschiedenen Stadien des Prostatakarzinoms https://www.leitlinienprogramm-onkologie.de/leitlinien/prostatakarzinom/

Wein, A. J.; Kavoussi, L. R.; Partin, A. P. & Peters, C. A. Campbell-Walsh Urology
. Elsevier, 2015. ISBN 978-1455775675.

Touma u.a. 2005 TOUMA, N. J. ; IZAWA, J. I. ; CHIN, J. L.: Current status of local salvage therapies following radiation failure for prostate cancer.
In: J Urol
173 (2005), Nr. 2, S. 373–9

A. W. Partin, C. A. Peters, L. R. Kavoussi, R. R. Dmochowski, and A. J. Wein, Campbell-Walsh-Wein Urology, 12th ed. ISBN-13: 978-1455775675: Elsevier, 2020.

Wirth u.a. 2002 WIRTH, M. P. ; HERRMANN, T. ; ALKEN, et a.: [Recommendations for permanent, interstitial brachytherapy alone in localized prostate carcinoma].
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  Deutsche Version: Therapie des Prostatakarzinoms mit Seeds, Brachytherapie oder HIFU