Cryotherapy, HIFU, and Other Ablative Treatments for Prostate Cancer

Ablative treatments use extreme heat or cold or other methods to destroy (ablate) prostate tissue, rather than removing it with surgery or treating it with radiation.

Ablative therapies might be used to treat the whole prostate gland, or just to treat the part of the prostate where the cancer is thought to be (which is known as focal therapy).

The main advantage of focal therapy is that it is likely to have fewer side effects than treatments that affect the whole prostate, such as surgery or radiation. However, it can have some limitations as well. For example:

• It’s not yet clear if focal treatments work as well in the long term (although if the cancer does come back, these treatments can often be repeated, or other treatments can be tried).
• Focal therapy might not be a good option if the tumor is very close to the urethra (the tube that carries urine out of the bladder, which passes through the prostate) or the rectum.
• Men who get focal therapy typically still need the same type of follow-up after treatment as men who choose active surveillance.

Some types of ablative treatments, such as cryotherapy and high-intensity focused ultrasound (HIFU), might be options to treat prostate cancer in certain situations, such as after radiation therapy. Some doctors now offer these as initial treatment options for early-stage prostate cancers that are at low risk of growing and spreading, especially in men who don’t want surgery or radiation but aren’t comfortable with just active surveillance. However, most expert groups don’t recommend ablative therapies as the first treatment for prostate cancer, unless surgery and radiation aren’t good options. This is mainly because there isn’t enough long-term data to show that these treatments are as effective as surgery or radiation.

Other types of ablative treatments, such as photodynamic therapy (PDT) and focal laser ablation (FLA), are still being studied for treating prostate cancer, and most doctors still consider them to be experimental at this time.

Cryotherapy 

Cryotherapy (also called cryosurgery or cryoablation) is the use of very cold temperatures to freeze and kill prostate cancer cells. Even though it is sometimes called cryosurgery, it’s not actually a type of surgery.

Compared with surgery or radiation therapy, doctors know much less about the long-term effectiveness of cryotherapy. While some forms of cryotherapy have been around for decades, modern cryotherapy techniques are still fairly new, so less is known about them.

When is cryotherapy used?

Cryotherapy is sometimes used if the cancer has come back after radiation therapy.

It may be an option to treat men with low-risk, early-stage prostate cancer who can’t have surgery or radiation therapy. However, most doctors don’t use cryotherapy as the first treatment for prostate cancer.

As with brachytherapy, this may not be a good option for men with large prostate glands.

How is cryotherapy done?

This procedure can be done with spinal or epidural anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are in a deep sleep).

The doctor uses transrectal ultrasound (TRUS) to guide several thin, hollow probes (needles) through the skin between the anus and scrotum and into the prostate. Very cold gases are then passed through the needles to create an ice ball that freezes and destroys the prostate tissue. Warmer gases are then passed through the probes to thaw out the area. This process is usually repeated.

To be sure the prostate tissue is destroyed without too much damage to nearby structures, tiny probes are put in and around the prostate before the procedure to monitor the temperature. The doctor also carefully watches the ultrasound during the procedure to make sure the right areas are being treated. Warm saltwater is passed through a catheter in the urethra to keep it from freezing. The catheter is left in place for several weeks afterward to allow the bladder to empty while you recover.

After the procedure, you might need to stay in the hospital overnight, but many men can go home the same day.

Cryotherapy is less invasive than surgery, so there is usually less blood loss, a shorter hospital stay, a shorter recovery period, and less pain.

Possible side effects of cryotherapy

Side effects from cryotherapy depend on how much of the prostate is treated. They tend to be worse if it is done in men who have already had radiation therapy, compared to men who have it as their first treatment.

Most men have blood in their urine for a day or two after the procedure, as well as soreness in the area where the needles were placed. Swelling of the penis or scrotum is also common.

Freezing might also affect the bladder and rectum, which can lead to pain, burning sensations, and the need to empty the bladder and bowels often. Most men recover normal bowel and bladder function over time.

Freezing often damages the nerves near the prostate that control erections. Erectile dysfunction is more common after cryotherapy than after radical prostatectomy. For information on coping with erection problems and other sexuality issues, see Sexual Side Effects.

Urinary incontinence (having problems controlling urine) is rare in men who have cryotherapy as their first treatment for prostate cancer, but it is more common in men who have already had radiation therapy.

A very small percentage of men develop a fistula (an abnormal connection) between the rectum and bladder after cryotherapy. This rare but serious problem can allow urine to leak into the rectum, and it often requires surgery to repair.

High-intensity focused ultrasound (HIFU)

HIFU uses highly focused ultrasound beams to heat and destroy prostate tissue. This treatment is still fairly new in the United States, although it’s been used in some other countries for many years.

While HIFU devices have been approved by the US Food and Drug Administration (FDA) to destroy prostate tissue (and therefore doctors can use them to treat prostate cancer), these devices have not been approved specifically to treat prostate cancer. It’s not yet clear how the long-term effectiveness of HIFU compares to surgery or radiation therapy.

When is HIFU used?

HIFU might be a treatment option if prostate cancer has come back after radiation therapy.

Some doctors now offer HIFU as the first treatment for early-stage prostate cancers that are at low risk of growing and spreading. However, most expert groups in the United States don’t recommend HIFU as a first-line treatment for prostate cancer at this time.

How is HIFU done?

This procedure can be done with either spinal anesthesia (where the lower half of your body is numbed) or general anesthesia (where you are in a deep sleep).

A special ultrasound probe is inserted into the rectum, and it’s first used to create 3D images of the prostate. These can be fused with images from other tests such as MRI, which can help the doctor determine which areas of the prostate need to be treated. The probe is then used to create focused, high-intensity ultrasound beams that precisely heat and destroy those areas of the prostate. The procedure typically takes 1 to 4 hours.

After the procedure, you’ll have a urinary catheter, which will stay in place for up to a week. Most men can go home the same day.

Possible side effects of HIFU

Side effects after treatment can include:

• Pain in the treatment area
• Blood in the urine
• An increased risk of a urinary tract infection (UTI)
• Having trouble urinating
• Feeling the need to urinate often

The risks of long-term problems, such as urinary incontinence and erectile dysfunction, are likely to be lower than they are with treatments such as surgery or radiation therapy, although they are still possible.

Other types of ablative therapies

Other types of ablative treatments are being developed as well. Some of these are now available, although most expert groups believe they need to be studied further before they become commonly used. Examples include:

Transurethral ultrasound ablation (TULSA): This procedure is similar to HIFU (described above) in that it uses high-intensity ultrasound beams to precisely heat and destroy parts or all of the prostate. But for TULSA, a thinner ultrasound probe is inserted through the tip of the penis and into the urethra (which runs through the prostate), rather than being inserted into the rectum. Real-time MRI is then used to image the prostate and guide treatment.

Focal laser ablation (FLA): In this approach, a thin laser fiber is inserted into the prostate near the tumor. This is typically done using MRI images for guidance, although some researchers are now studying the use of ultrasound as well. The laser is then activated to heat and destroy the prostate tissue.

Photodynamic therapy (PDT): For PDT, a light-activated drug is injected into the blood through an IV. A short time later, a low-energy laser light source is inserted into the prostate and directed at the tumor using thin optical fibers. The light activates the drug, which then destroys the blood vessels around the tumor. This procedure, which is also known as vascular-targeted photodynamic therapy (VTP), is not yet available in the United States. To learn more about PDT in general, see Getting Photodynamic Therapy.

Irreversible electroporation (IRE): For this treatment, long needles (electrodes) are place around the tumor to create a strong electrical field within the tumor. This causes holes (pores) to form in the walls of the cancer cells, leading to their death. This approach doesn’t use heat or cold to destroy the cells, so it might prove useful in areas where it’s important to protect vital structures like nearby blood vessels.