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Prostate Cancer: TURP, HIFU, Cryotherapy and Focal Therapy

• Prostate cancer (1/14): Definition and epidemiology
• Prostate cancer (2/14): Etiology
• Prostate cancer (3/14): Pathology
• Prostate cancer (4/14): Signs and symptoms
• Prostate cancer (5/14): Screening
• Prostate cancer (6/14): Staging
• Prostate cancer (7/14): Treatment options
• Prostate cancer (8/14): Active surveillance
• Prostate cancer (9/14): Prostatectomy
• Prostate cancer (10/14): Radiation therapy
• Prostate cancer (11/14): Brachytherapy
• Prostate cancer (12/14): TURP and experimental treatment options
• Prostate cancer (13/14): Hormonal therapy of advanced prostate cancer
• Prostate cancer (14/14): Treatment of castration-resistant prostate cancer

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. 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:

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.

References

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. N. Mottet (Chair), J. Bellmunt, E. Briers (Patient Representative), R.C.N. van den Bergh (Guidelines Associate), M. Bolla, N.J. van Casteren (Guidelines Associate), P. Cornford, S. Culine, S. Joniau, T. Lam, M.D. Mason, V. Matveev, H. van der Poel, T.H. van der Kwast, O. Rouvière, T. Wiegel Guidelines on Prostate Cancer of the European Association of Urology (EAU), https://uroweb.org/guideline/prostate-cancer/.

Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Interdisziplinäre Leitlinie der Qualität S3 zur Früherkennung, Diagnose und Therapie der verschiedenen Stadien des Prostatakarzinoms, Langversion 3.1, 2014 AWMF Registernummer: 034/022OL, http://www.awmf.org/leitlinien/detail/ll/043-022OL.html (Zugriff am: 07.02.2016)

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. 2593–7Wein, A. J.; Kavoussi, L. R.; Partin, A. P. & Peters, C. A. Campbell-Walsh Urology
. Elsevier, 2015. ISBN 978-1455775675.

  Deutsche Version: Prostatakarzinom