Cryoablation in BPH (Benign prostatic hypertrophy)

What is cryoablation?

The aim of cryoablation is to kill the target tissue by freezing at very low temperatures (minus 140-190 degrees Celcius). The dead tissue will become harmless and absorbed by your body's immune system over months. Unlike other heat-based ablation methods like laser, microwave, radiofrequency and vapor, cryoablation has several advantages which make it more suitable in the prostate:

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• It is much less painful, because ice is a natural local anesthetic. Thus, no general/spinal anesthesia is needed. 

• The ice is visible on ultrasound, CT and MRI. Thus the doctor can control the ablation much better during the procedure.

• It is much less harmful to the collagen-containing structures such as vessels, urine channels, sperm channels and muscles. For this reason, even if you freeze a large prostate tissue urethra, sphincters and sperm channels are protected. 

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At our centers, we have used percutaneous cryoablation nearly for two decades in thousands of patients with cancers (prostate, kidney, lung, liver, soft tissue, breast, pancreas and thyroid) as well as benign tumors ( fibroadenomas, desmoid tumors and thyroid nodules). In the world, the history of cryoablation in the prostate goes beyond 30 years. For decades, it has been successfully used in the treatment of prostate cancers by many doctors. Although it was very successful in prostate cancer, cryoablation was not used for the treatment of BPH until recently. At our centers, we noticed that the patients that we treated with cryoablation for cancer had also improvement of their BPH symptoms. Based on this observation, in patients with boths cancer and BPH, we started cryoablation of the prostatic tissue around the urethra besides the cancer in the prostate. We have seen in these patients that they became not only free from the cancer but also from the prostate symptoms. Over the time, we started treating also BPH patients without cancer by using cryoablation. We are very happy to see that so far all the patients had a significant improvement of their BPH symptoms and none of them developed any major side effect like retrograde ejeculation, impotance, incontinence and urethral narrowing. 

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How do we do cryoablation for BPH?

At our centers, percutaneous cryoablation is done typically with local anesthesia and sedation. We put the patient in a lithotomy position (the legs separated, flexed, and supported in raised stirrups). The perineal region (skin between the testicles and anus) is disinfected and numbed by injecting a local anesthetic like lidocaine. Then we put the transrectal ultrasound probe into the anus and image the prostate. We then place the cryo needle (cryoprobe) from the perineum into the prostate, typically parallel to and 1 cm from the urethra. When the cryoablation machine is turned on, an ice ball is formed around the cryoprobe which reaches to around 3 cm in diameter in 10 minutes. The formation and growth of the ice ball is seen continuously by the doctor on ultrasound, and if it reaches to critical structures like nerves and bowels the process may be stopped and the ice ball may be melted. In this way, a maximum ablation can be achieved without harming the sensitive structures.

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During the prostate cryoablation, we put a urine catheter and protect the urethra from freezing by circulating warm urine through this catheter. We typically remove this catheter one hour after the procedure. About 95% of our patients are able to urinate normally and discharged without a catheter. In the remaining 5%, patients may have difficulty in urinating and the catheter is kept in for a couple of days and then removed. Most patients urinate more comfortably in 2 weeks after cryoablation although maximum benefit is observed at 3-6 months. 

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Why is cryoablation better in BPH?

In our patients, we have consistently seen a markedly improved quality of life while we have never seen any major side effects. For this reason, cryoablation has become our first choice in the treatment of BPH at our centers. We also belive that it will also become the first line treatment of BPH in all over the world in near future. This belief is based on our following observations:

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• Cryoablation is not a new tool. It has been used in the prostate for over 3 decades for cancer. Its advantages and limitations are very well-known. What's new is its use in benign prostatic hyperplasia.

• Cryoablation is much less painful than any other procedure because ice has a local anesthetic effect.

• Cryoablation does not cause a significant harm to urethra, sperm channels and sphincter muscles. As a result, retrograde ejeculation, impotance, incontinence and urethral narrowing are not seen. 

• Cryoablation is safer than other procedures. Because the ice can be seen on ultrasound, the doctor can see the ablation area continuously and can better protect the sensitive structures. 

• If a patient has both BPH and an early prostate cancer, we can treat both conditions with cryoablation in a single session.

• Since it is able to kill cancers, any cancerous tissue that may be present in the ablation area will have been killed by cryoablation.

• Unlike other procedures, cryoablation can be used in BPH caused by median lobe hypertrophy and also in all (small, medium and large)  prostates.

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