Cryo-Forum

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Over the last few years urologists, in the U.S. in particular, have discussed, at times harshly, on the introduction of cryosurgery in addition or even as an alternative to radiotherapy and open surgery in the treatment of prostate cancer in open contrast with many urologists who have fought, at all costs, the idea of any such possibility.

As it often happens among men, conflicts of ethical, economic, cultural and generational nature have risen on both sides hiding behind apparently unquestionable scientific reasoning which, in fact, often have a partly emotional and personal derivation. All this is well known to those who have taken part in the controversy.

Now that, after some years of isolation, my friend Dr. Graham Watson and I are being joined by illustrious and enthusiastic cryosurgeons in Europe, and that cryosurgery is finally spreading over the Old Continent, I would like to make some personal considerations on the problems related to it, hoping it may become food for thought to both friends and foes of past, present and future.

I therefore thank Prof. Ivo Kraljic, and through him the entire Croatian urological community, for hosting me on the first issue of the new Acta Urologica Croatica, to express my thought on the subject.

The first remark that should be made is that, as we approach the third millennium, the scientific community unanimously agrees on which is the best cure for PCA in one case only, and that is when the neoplasm is organ-confined.

All urologists agree that those patients with locally restricted carcinoma who have a greater life-expectancy than what may be assumed from medical therapy, should undergo surgery in the form of radical prostatectomy. On the other hand, those patients who show such locally progressed pathology that can rarely recover through surgery should undergo total androgen ablation.

Unfortunately, however, we do not really know exactly what the life expectancy of a patient with confined desease is especially when treated with the new non surgical therapies. What is more, we have only one certain and unequivocal "staging method" available in order to choose the best candidates for surgery or medical therapy: the distinction betweeno these two categories is given by a 5-year follow-up of those patients who have already undergone surgery; which is, of course, a paradox. But it is sadly true that too often only after surgery we know who should have really undergone it.

This is further confirmed by the fact that, as is well known, a large number of cases who are believed to be locally confined after a pre-operative staging, turn out to be not confined upon a final histological examination. There are even cases in which the pathology had a progression even though both lymphonodes and specimen margins were negative at surgery; and their percentage is such that it cannot be disregarded.

We should therefore conclude that we do not have sufficient staging methods. But, do we make proper use of what we have at our disposal?

1. Does the operator personally carry out the u.s. and the biopsies of his patients?
2. Are the data in the record sufficiently clear and structured so as to allow a stereotactic reconstruction of the neoplasm shape and limits?
3. Are the fragments being gathered so as to allow an adequate histological process?
4. Are the fragments stained at one extremity?
5. Are you sure that the lab technician who prepares the slides uses all the tissue available in the preparation?
6. Is the fragment placed on the slide being compared with what the pathologist has described in the records when he received it (only then will we know if an all-round assessment has been made on all the length of specimens collected)?
7. Does the pathologist show the urologist how to look at the preparation himself?
8. Does the urologist examine the slides himself?
9. Does the pathologist learn how the urologist takes the specimens?
10. Does the urologist-ultrasonographer teach and learn from the pathologist?
11. Does he discuss the single cases with the pathologist?
12. Are all available data being compared to the CAT and MRN scannings (if used)?

Now we are ready to take-off (surgery) and all we have to do is to explain to the passenger-patient where we want to take him and why.

In any case, we must always bear in mind the route through which we will lead our passengers (hopefully) safely to destination and, in spite of the great limits our knowledge still has, if the check-off list has been carried out properly, we can at least try to fly.

This kind of process will support theurapeutical advices. If a surgical solution is advised and accepted, an objective (and partly presumed-inferred) tridimensional map of the taken or risk-laden area will allow a more specific surgical strategy for each patient.

One may, at this point, object that, in the real world, there is no time for this kind of approach. However, cancer is a very "real" thing to the patient, and we should therefore make all possible efforts to find the best approach to each individual situation.

This methodology is particularly necessary in the case of cryosurgery. Cryosurgical techniques, in fact, may and therefore must be modelled to the individual anatomopathological behaviour more than in traditional surgery.

I believe that cryosurgery may be applied to the prostate in many of those cases in which traditional surgery cannot give absolute guarantees of total cancer removal.