CRYOABLATION AS A PRIMARY PROSTATE CANCER TREATMENT FOLLOWED BY PENILE REHABILITATION - PowerPoint PPT Presentation

1 / 1
About This Presentation
Title:

CRYOABLATION AS A PRIMARY PROSTATE CANCER TREATMENT FOLLOWED BY PENILE REHABILITATION

Description:

... ring to create and maintain erection for 5 minutes at least once per day ... as the ability to achieve an erection sufficient for intercourse with or without ... – PowerPoint PPT presentation

Number of Views:275
Avg rating:3.0/5.0
Slides: 2
Provided by: drjohncr
Category:

less

Transcript and Presenter's Notes

Title: CRYOABLATION AS A PRIMARY PROSTATE CANCER TREATMENT FOLLOWED BY PENILE REHABILITATION


1
CRYOABLATION AS A PRIMARY PROSTATE CANCER
TREATMENT FOLLOWED BY PENILE REHABILITATION
DAVID S. ELLIS, MD, UROLOGY ASSOCIATES OF NORTH
TEXAS A summary of results published in Urology,
2007 Feb69(2)306-10
INTRODUCTION Although cryoablation was first
studied in the 1960s, it has only recently been
accepted as definitive treatment for prostate
cancer1. This is due, in large part, to technical
advances in the procedure that have made the
procedure safer and consistently efficacious2.
Both ultrasound4 and temperature monitoring are
now used to monitor the procedure and the
development of argon based technology improved
the consistency of cryoprobe performance. Greater
understanding of cryobiology as well as animal
and human investigations have led to the
definition of clinical endpoints for effective
ablation and treatment planning3-5. As well,
consistent use of an approved urethral warmer has
decreased urethral complications including
sloughing and incontinence10. Lastly, the use of
two posterior-medial cryoprobes rather than a
single posterior-central cryoprobe has reduced
the fistula rate to lt0.56-8. We report a
consecutive series of patients who underwent
modern prostate cryoablation by a single surgeon
as a primary therapy for localized prostate
cancer. Those patients potent at the time of
intervention were encouraged to regularly utilize
penile vacuum therapy after treatment in hopes of
preserving or recovering erectile function.
RESULTS Between December 2000 and 2005, 416
consecutive patients underwent cryoablation as
primary therapy for localized prostate cancer.
Patient demographics are summarized in Table 1.
Of patients whose continence status was known
prior to cryoablation, 97.1 (384/395) were
continent. Potency status was known for 325
patients prior to cryoablation, 127 of whom
(39.1) were potent. Mean follow-up of all
patients was 20.414.7 months (range 1.5 to 60,
median 60). Sufficient follow-up to determine
biochemical survival was available for 291
patients with a mean follow-up of 25.913.1
months (range 9 to 60, median25). The
procedure was well tolerated with no
post-operative deaths and no rectal fistulas. Of
the 384 patients continent at the time of
treatment 327 had 6 month follow up with known
continence status thirteen of which were
incontinent (4.0). Stratifying by severity, two
(0.6) had total incontinence (requiring use of
absorbent pads) and eleven (3.4) had stress
incontinence. All patients were impotent
immediately following cryoablation. Kaplan-Meier
analysis demonstrating the time dependent return
to potency is shown in Figure 1. At one, two and
four years, the probability a patient who was
potent at the time of intervention regaining
their ability to have intercourse with or without
oral pharmaceutical assistance was 29.14.3,
48.55.0 and 51.35.9, respectfully. The mean
and median PSA nadirs were 0.45 and 0.1ng/ml,
respectively. A PSA nadir lt0.4ng/ml was achieved
by 79.7 of the population. Kaplan-Meier analysis
revealed a four-year BDFS of 79.6.24 for the
entire population (Figure 2a). When stratified by
risk group 83.63.8, 82.33.6 and 69.15.5 of
low, moderate and high-risk patients,
respectively, remained disease free at four years
(Figure 2b). The mean time to biochemical failure
according to the scientific definition was 4.2
months with a mean time to being clinically
evident of 14.2 months. Post therapy, 168
patients underwent biopsy, seventeen were
positive (10.1) at a mean of 10.2 months
post-treatment. This yields a positive biopsy
rate for the entire population of 4.1 (17/416).
Figure 2 Kaplan-Meier Survival Curves for (a)
all patients and (b) patients stratified by risk
group
COMMENT Past studies have shown that
incontinence, when modern cryotechnology is used,
ranges from 1.37 to 7.58. The 4.0 incontinence
rate (0.6 total 3.4 stress) from the current
series fits well within previously recorded
ranges. No rectourethral fistula occurred in our
series. This is not surprising as reports
utilizing argon based cryoprobes have stressed
(and we echo) that urethral fistulas are no
longer a morbidity expected post cryoablation3.
What is different from previous cryoablation
reports is the potency rate observed in the
current series. Impotence is expected immediately
following cryoablation. However, for some
patients it proves to be transient with recovery
noted as far as five years post-treatment. In a
prospective study Robinson et al found recovery
of erectile function with time9. Within 3-years
of the procedure 47 of men who were having
intercourse prior to cryoablation returned to
intercourse with or without the use of oral or
device ED aids. Our series, which encouraged
patients to engage in a penile rehabilitation
effort with regular use of a vacuum therapy
device without constriction ring, shows a potency
rate of 29.14.3 at one-year and 51.35.9 at
four-years. This is substantially higher recovery
than any other series published to date and the
return appears to be expedited compared with that
of Robinson9. We believe that the manner in
which the procedure was presented to the patients
as well as the use of penile rehabilitation was
instrumental in helping our patients regain
sexual function. Patients were told at initial
consultation and again immediately pre-treatment
that (based on the results of Robinson9) they
would be impotent immediately following
cryoablation but it was not necessarily true that
they would remain impotent. This may have created
a hopeful atmosphere for the patient increasing
their probability of regaining erectile function
This, we believe, in concert with regular use of
a vacuum device without a constriction ring in
attempt to both oxygenate the penis and prevent
atrophy, is responsible for the rapid and high
rate of return of sexual function.
Brachytherapy has reported potency rates,
ranging from 49-10010. This study demonstrates
that potency rates within the range of
brachytherapys may be achieved following
cryoablation. It is important to note that in
this study all prostates were aggressively and
treated with total gland (i.e., non-focal)
cryoablation.
METHODS All procedures were performed with the
Cryocare System (Endocare, Inc., Irvine, CA) with
ultrasound guidance. Temperatures in and around
the gland were monitored with thermosensors. A
felxible urethral warming catheter was used to
protect the urethra and adjacemnt structures such
as the bladder neck and external sphincter.
Patients potent at the time of intervention
were strongly encouraged to utilize a vacuum
therapy device (Firma Medical, Mansfield, TX)
without constriction ring to create and maintain
erection for 5 minutes at least once per day
beginning six weeks post cryoablation and
continuing until erections returned. They were
also instructed to take oral ED pharmaceuticals
once every other day beginning six months after
cryoablation and until the return of satisfactory
erections, then when necessary for intercourse.
For the purposes of this study, incontinence
was defined as any patient experiencing any
leakage of urine regardless of number of pads
worn (if any) six-months following cryoablation.
Potency, evaluated every 6 months, was defined as
the ability to achieve an erection sufficient for
intercourse with or without oral pharmaceutical
assistance. Patients utilizing a vacuum device
for intercourse were not considered potent. Only
those patients continent and potent,
respectively, at time of intervention were
included in the post-treatment potency and
continence analysis. Biochemical disease free
survival (BDFS) was determined using a modified
American Society of Therapeutic Radiation
Oncology (ASTRO) definition of three successive
rises in PSA with a final value gt 1.0 ng/ml. To
determine biochemical survival a minimum of four
post treatment PSA measurements are needed. Only
patients with sufficient follow-up were included
in the Kaplan-Meier analysis of biochemical
survival. All patients treated in the first
twelve months of our experience (n93) underwent
a 12 core biopsy 1 year post treatment.
Subsequent to this, due to the very high negative
biopsy rate of this group15, patients were
biopsied if their PSA exceeded 1.0 ng/ml. If
biopsies were negative, a bone scan was
performed.
Table 1Patient demographics
CONCLUSION Modern cryoablation as a primary
intervention performed in a community hospital
setting is an effective and safe primary therapy
for localized prostate cancer. The effect of
cryoablation on erectile function appears to be
minimized when a patient is correctly informed
that recovery of erectile function is possible.
Also, use of a penile rehabilitation program
after cryoablation may expedite the return of
erectile function.
Figure1 Kaplan-Meier prediction of potency
recovery
REFERENCES 1. Whyte, J. J., Bagley, G. P., and
Kang, J. L. The Health Care Financing
Administration cryosurgery decision a timely
response to new data. J Urol, 162 1386-7, 1999
2. Katz, A. E. and Rewcastle, J. C. The current
and potential role of cryoablation as a primary
therapy for localized prostate cancer. Curr Oncol
Rep, 5 231-8, 2003 3. Lee, F., Bahn, D. K.,
Badalament, R. A., Kumar, A. B., Klionsky, D.,
Onik, G. M. et al. Cryosurgery for prostate
cancer improved glandular ablation by use of 6
to 8 cryoprobes. Urology, 54 135-40, 1999 4.
Hoffmann, N. E. and Bischof, J. C. The
cryobiology of cryosurgical injury. Urology, 60
40-9, 2002 5. Larson, T. R., Robertson, D. W.,
Corica, A., and Bostwick, D. G. In vivo
interstitial temperature mapping of the human
prostate during cryosurgery with correlation to
histopathologic outcomes. Urology, 55 547-52,
2000 6. Bahn, D. K., Lee, F., Silverman, P.,
Bahn, E., Badalament, R., Kumar, A. et al.
Salvage cryosurgery for recurrent prostate cancer
after radiation therapy a seven-year follow-up.
Clin Prostate Cancer, 2 111-4, 2003 7.
Donnelly, B. J., Saliken, J. C., Ernst, D. S.,
Ali-Ridha, N., Brasher, P. M., Robinson, J. W. et
al. Prospective trial of cryosurgical ablation
of the prostate five-year results. Urology, 60
645-9, 2002 8. Long, J. P., Bahn, D., Lee, F.,
Shinohara, K., Chinn, D. O., and Macaluso, J. N.,
Jr. Five-year retrospective, multi-institutional
pooled analysis of cancer-related outcomes after
cryosurgical ablation of the prostate. Urology,
57 518-23, 2001 9. Robinson, J. W., Donnelly,
B. J., Saliken, J. C., Weber, B. A., Ernst, S.,
and Rewcastle, J. C. Quality of life and
sexuality of men with prostate cancer 3 years
after cryosurgery. Urology, 60 12-8, 2002 10.
Incrocci, L., Slob, A. K., and Levendag, P. C.
Sexual (dys)function after radiotherapy for
prostate cancer a review. Int J Radiat Oncol
Biol Phys, 52 681-8, 2002 30. Onik, G.,
Narayan, P., Vaughan, D., Dineen, M., and
Brunelle, R. Focal "nerve-sparing" cryosurgery
for treatment of primary prostate cancer a new
approach to preserving potency. Urology, 60
109-14, 2002.
Write a Comment
User Comments (0)
About PowerShow.com