CRYOTHERAPY - THE CHALLENGE OF REDUCING THE COMPLICATIONSSeptember 1997
Graham Michael Watson MD FRCS (Urol)
Eastbourne District General Hospital, Easbourne, United Kigdom
The Literature reports a widley varying incidence of complications from cryotherapy for prostate cancer. Fistulae tend to occur early in the series and are then avoidable with certainty. Incontinence is reported between 2.3% and 27%. impotence is quoted between 65% and 100%.
We have divided our series into four phases. Our initial phase performed on 19 patients involved a single freeze of the entire gland. 3 patients had stress incontinence persisting for more than three months but less than six months. Only 9 of the 19 patients were biopsy negativeat 3 months. In the second phase the patients were treated with more radical freezing of the prostate and sorrounding structures but with more warming of the rectum. There were two prostatorectal fistulae, 2 patients were rendered grossly incontinent and a third patient had stress incontinence. 9 out of 11 patients were biopsy negative at three months. In the third phase 15 patients were treated with a double freeze thaw cycle of the entire prostate. there were no cases of prostatorectal fistulae. 2 patients had persisting incontinence at one year and 4 patients had incontinence lasting more than three months which resolved by six months. Our current approach is to preserve the phincter active area while freezing the apex. Since adopting this approach all our patients have been totally continent from the moment of re-establishing voiding.
Radical cryotherapy for prostate cancer - although minimally invasive - carries the risk of very significant morbidity. Prostatorectal fistulae can be avoided provided that the iceball is not allowed to extend deeply into the rectal wall. Incontinence can occur after cryotherapy and it can be very long lasting. By ensuring that the free zones di not extend into the sphincter active region one can avoid any diminuition in continence without apparently compromizing on efficacy.
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