Urology Textbook
Clinical Essentials
By Dirk Manski, MD

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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

Indication:

Palliative transurethral resection of the prostate (TURP) is indicated for symptomatic subvesical obstruction when radical prostatectomy is not an appropriate treatment option.

Surgical Technique:

See section TURP.

Results:

TURP cannot provide curative treatment. Compared with TURP for BPH, palliative resection of the prostate for subvesical obstruction has a higher complication rate, particularly urinary incontinence, postoperative urinary retention, bleeding, and repeat surgery. Limited resection is often performed to avoid incontinence.

Experimental Focal Treatment Options for Localized Prostate Cancer

Focal Therapy for Prostate Cancer:

Advances in imaging (see multiparametric MRI) enable localization of clinically significant prostate cancer lesions. If the disease is limited to 1–2 lesions, focal treatment of these lesions may be considered. Focal therapy is possible with HIFU, brachytherapy, IRE, or cryotherapy. The remaining prostate is not treated to avoid adverse effects. Focal therapy may be offered to patients who meet the criteria for active surveillance but nevertheless desire treatment with few adverse effects. Follow-up after focal therapy, analogous to active surveillance, consists of regular mpMRI and prostate biopsies. If tumor progression requires salvage treatment, prior focal therapy may result in poorer oncologic and functional outcomes.

High-Intensity Focused Ultrasound Ablation (HIFU):

A transrectal ultrasound probe delivers high-energy ultrasound waves that destroy prostate tissue. The result is tissue necrosis, which is degraded or sloughed by the body. In principle, HIFU can treat the index lesion, perform hemiablation, or treat the entire prostate gland while sparing the urethra. Available data are limited to retrospective series with a maximum follow-up of 14 years. In summary, oncologic outcomes depend on established risk factors and are comparable with radiotherapy (Ganzer et al., 2013). Adverse effects include erectile dysfunction, urinary incontinence, and persistent subvesical obstruction in up to 30 %, which can be treated with neoadjuvant or adjuvant TURP. Severe complications such as rectal fistulae are rare.

Cryotherapy:

Perineal cryoprobes are positioned in the prostate under TRUS guidance; additional temperature-sensor needles are used for temperature control. Modern cryotherapy devices can apply freezing and thawing cycles rapidly and precisely, and TRUS provides good visualization of ice-ball formation (Touma et al., 2005). As focal therapy or hemiablation, cryotherapy is intended to provide tumor control with better preservation of continence and erectile function. Complications include urinary retention, persistent subvesical obstruction, urethral stricture, urinary incontinence, erectile dysfunction, rectourethral fistula, and osteitis pubis. Randomized comparative studies with long-term follow-up are lacking.

Irreversible Electroporation (IRE):

Perineally inserted needle electrodes apply an electrical current that disrupts cell membranes and subsequently causes tissue necrosis. The relatively mild current application is intended to protect sensitive structures better than the thermal techniques described above; adverse effects are often transient and mild. Controlled comparative studies or retrospective series with long-term follow-up are lacking with regard to 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

References

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
173 (2005), Nr. 5, S. 1562–6

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].
In: Urologe A
41 (2002), Nr. 4, S. 369–73



  Deutsche Version: Therapie des Prostatakarzinoms mit Seeds, Brachytherapie oder HIFU

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