Care ‘n’ Cure Urology Clinic

Currently, digital rectal examination (DRE) and prostate specific antigen (PSA) are used for prostate cancer detection.
DRE: The DRE is performed with the man either bending over, lying on his side or with his knees drawn up to his chest on the examining table. The physician inserts a gloved finger into the rectum and examines the prostate gland, noting any abnormalities in size, contour or consistency. DRE is inexpensive, easy to perform and allows the physician to note other abnormalities such as blood in the stool or rectal masses, which may allow for the early detection of rectal or colon cancer. Because the DRE by itself is not an effective way to detect early cancer, it should always be combined with a PSA test.
Prostate Specific Antigen Test (PSA): The PSA test is usually performed in addition to DRE. The test measures the level of PSA, a substance produced only by the prostate, in the bloodstream.
The blood test can be done in a clinical laboratory, hospital or physician's office and requires no special preparation on the part of the patient. Ideally, the test should be taken before a DRE is performed or any catheterization or instrumentation of the urinary tract. Furthermore, because ejaculation can transiently elevate the PSA level for 24 to 48 hours, the patient should abstain from sexual activity for two days prior to having a PSA test.
Very little PSA is detected from patients with a healthy prostate, but certain prostatic conditions can cause larger amounts of PSA to leak into the blood. One possible cause of a high PSA level is benign (non-cancerous) enlargement of the prostate, otherwise known as BPH. Inflammation of the prostate, called prostatitis is another common cause of PSA elevation, as is recent ejaculation. Prostate cancer is the most serious possible cause of an elevated PSA level. The frequency of PSA testing remains a matter of some debate.
The American Urological Association (AUA) believes that the decision to screen is one that a man should make with his doctor following a careful discussion of the benefits and risks of screening.

Because not all prostate cancer is the same and not all are life threatening, it is important to understand the treatment options you choose should be very specific to your personal health history. It is an individual decision that patients should make together with their doctor and their family. No one treatment is perfect for every man.
Several factors come into play when selecting the best treatment for an individual and they include:
• Tumor stage (extent of local spread) and grade (aggressiveness),
• PSA level (higher levels indicating a greater risk of cancer recurrence after treatment), and extent of disease (number of biopsy cores with cancer), as well as
• competing medical co-morbidities (other diseases that can affect life expectancy) and
• Age at diagnosis (as most prostate cancers take many years to become evident and cause morbidity, the same tumor in an older man may pose a lower risk of causing problems in his lifetime); all play a role in the decision regarding the choice of therapeutic intervention

It is important that you speak to your doctor about which treatment is right for you.
Below is a list of the common medical treatments for localized prostate cancer:
• Active Surveillance
• Surgery
• Radiotherapy
• Cryotherapy

Prostate cancer is often a slow progressive disease, and many men with prostate cancer will die from causes other than prostate cancer. Your physician may recommend the active surveillance treatment option if you have been diagnosed with a very early stage of prostate cancer.
Active surveillance is a type of close follow-up for men with prostate cancer. This follow-up usually involves regular prostate-specific antigen (PSA) tests, digital rectal examinations (DREs) and possible prostate biopsies. If these periodic tests show that your cancer is progressing, you and your doctor may begin to discuss other forms of treatment.
The goal of active surveillance is to allow men to maintain their quality of life when the prostate cancer is slow growing or inactive, while allowing them to elect active treatment when the disease becomes more aggressive or begins to grow.

Active surveillance may be a suitable option for men who are not experiencing symptoms, or when the cancer is not expected to grow at an aggressive rate. Active surveillance allows men to maintain their quality of life, thus for those whom avoidance of sexual, urinary, and/or bowel complications are a primary consideration, active surveillance may be considered. Active surveillance can also be considered for men who are older or have other serious health conditions, which can make the cancer more difficult to treat immediately.
What are the advantages and disadvantages of Active Surveillance?
There are two advantages for utilizing this treatment option – low cost and no immediate complications.
The risk of active surveillance is that the cancer could grow and spread to other parts of the body between follow-ups, making it more difficult to treat. Not all prostate cancers require active treatment, and not all prostate cancers are life threatening. The decision to implement active treatment is one a man should discuss in detail with a urologists to determine whether active treatment is necessary, or whether surveillance may be an option.
Surgery

In general, prostate cancer surgery is best performed in patients with clinical stage T1 or T2 prostate cancer (confined to the prostate gland) and in selected men with clinical stage T3 disease. While there are no absolute cut-offs, men with a PSA level less than 20 ng/mL and a Gleason score of less than eight have a higher likelihood of cure. In certain circumstances, patients with more serious parameters are offered surgery. Prostate cancer surgery is usually restricted to men who are healthy enough to tolerate a major operation and have a 10-year or more life expectancy. Life expectancy is assessed by both patient age and health.
What types of surgeries are available to treat localized prostate cancer?
• Open Radical Prostatectomy
• Perineal Radical Prostatectomy
• Retropubic Radical Prostatectomy
• Minimally Invasive
• Robotic Assisted Laparoscopic Radical Prostatectomy
• Laparoscopic Radical Prostatectomy

A radical prostatectomy is the surgical removal of the entire prostate, the seminal vesicles, the nearest portions of the vas deferens, the tissue immediately surrounding them, and some of their associated pelvic lymph nodes. Because prostate cancer may be scattered throughout the prostate gland in an unpredictable way, the entire prostate must be removed to ensure that cancer cells are not left behind to continue to grow.
The pelvic lymph nodes are small oval or round bodies located along blood vessels that filter lymphatic fluid. For prostate cancer, the cascade of cancer spread is usually first to the soft tissues surrounding the prostate capsule, then to the seminal vesicles, then to the lymph nodes, and then to the bones and other organs of the body). There are many other lymph nodes, so the body will not be compromised by the removal of these few lymph nodes.
The surgery requires anesthetic, and the patient will be in the hospital for one to three days and then sent home with a urinary drainage tube (a catheter) in his bladder. The tube will be removed after one to two weeks.

In the perineal approach, the prostate is removed through an incision in the perineum behind the scrotum. By avoiding the complex pelvic veins, which can cause significant bleeding during the retropubic, laparoscopic, or robotic approaches, bleeding is uncommon with the perineal approach.
What are the advantages and disadvantages of the perineal radical prostatectomy approach?
Advantages to the perineal procedure include:
• precise urethra-vesicle anastomosis (re-attaching the urethra to the bladder),
• a smaller incision,
• generally less pain

The main disadvantages to the perineal approach include:
• higher incidence of rectal injury,
• difficulty of preserving the neurovascular bundles (muscles that control erections)
• a need for a separate incision for pelvic lymphadenectomy (surgical removal of one or more groups of lymph nodes)

However, most patients do not need a lymphadenectomy due to their very low risk of lymph node involvement. Typically, the perineal approach is preferred in obese individuals or those with prior lower abdominal surgery. In general, few urologic surgeons have significant experience with this approach

The main benefit of a radical prostatectomy is that once the prostate is removed so is all of the cancer if it had not spread to other parts of the body.
A radical prostatectomy has an advantage of providing accurate local staging. This means a doctor can determine the true extent of the disease including whether it has moved beyond the confines of the prostate as well as the potential for assessment of pelvic lymph nodes to determine if the cancer has spread to them.

For patients with prostate cancer pathologically confined to the prostate, the chance of cure with surgery alone at 10 years (undetectable PSA) is more than 90 percent. For men who have cancer progression (cancer beyond the capsule of the prostate gland) while surgery is a good option they may benefit from additional therapy. A recently published randomized trial showed men with metastasized prostate cancer improved their cure rate with the addition of radiation.
Radical prostatectomy has been compared to watchful waiting and has been shown to improve a man’s chance of survival. In a study, conducted in Scandinavia, men with clinically localized prostate cancer were randomly assigned to radical prostatectomy or to watchful waiting groups. In the study, men treated with surgery had a significant improvement in survival. Nonetheless, three additional observations were: (1) most men whose tumors were watched did not die from prostate cancer, (2) some men who underwent surgery did die from prostate cancer, and (3) about 20 operations were needed to save one life from prostate cancer.

The main disadvantage of the radical prostatectomy procedures are the complications that could arise from the operation itself; some occurring early and some late. Bleeding can occur in any major operation. Some surgeons recommend that the patient donate his own blood before surgery or receive a blood-stimulating hormone (Epogen, EPO) to boost his blood count and reduce the risk of needing a blood transfusion from an anonymous donor. Deep venous thrombosis (blood clots in the leg veins or pelvic veins) and pulmonary embolism (blood clot that goes to the lung) occur in approximately 1-2% of patients after radical prostatectomy.

Erectile dysfunction and urinary incontinence are the problems reported most often from this procedure. The chance of having erectile dysfunction depends on a main’s age and health, his sexual function before treatment, the stage of the cancer, and the ability to save the nerves that control erection during surgery. Younger men (those under the age of 60) are less likely to have problems with their erections than are older men. Even if erectile dysfunction does occur after surgery, erections may return to normal over time. There are also medications and devices to treat the problem that may be helpful. You may wish to speak to your doctor about various treatments.

Short-term incontinence after radical prostatectomy is also a common side effect. Many men will require a protective pad for several weeks to months after surgery. Fortunately, most men will ultimately recover urinary control. Long-term (after 1 year) incontinence is rare with occurrence in less than 5-10 percent of all surgical cases. However, when it does occur, there are procedures that can solve the problem.

Other problems reported by patients include irritation of the bladder, gastrointestinal symptoms, bladder infection, blockage of the urine flow from the bladder and leaking of urine. Sometimes scarring can occur and scar tissue may form in the bladder and urinary tract, changing the flow of urine. If a man’s urine flow is blocked, more surgery may be required.

With recent advances in minimally invasive surgery and computer technology, the prostate gland can now be removed through several one- to two-inch incisions in the patient's abdomen. Robotic prostatectomy utilizes a surgical robotic system (a device that holds surgical instruments and a laparoscopic camera to remove the prostate gland through laparoscopic access.
The primary advantage to this approach is less blood loss although transfusion rates do not appear to be different from open prostatectomy approaches when performed by an experienced surgeon. Initially, shorter hospital stays were seen with this approach but with improvements in open surgery, one-day hospital stays are the norm for the open surgery at many institutions.

Laparoscopic prostatectomy is a type of 'minimally-invasive' surgery that uses six 1-inch incisions, with one being slightly larger in order to extract the prostate gland from the abdomen. Through the small incisions, surgical instruments, including a camera, are inserted. The camera allows the surgeon to view inside the abdomen and perform the surgery while using laparoscopic instruments instead of the robotic arms. This technique is more technically challenging for the surgeon but, in experienced hands, has results that are similar to the robotic technique.

It is claimed that laparoscopic and robotic surgery is less invasive and that with the smaller incisions, the patient may experience less pain and scarring and a faster recovery than with the radical prostatectomy approaches. However, in another sense, it is more invasive, because the laparoscopic and robotic operations are performed within the peritoneal cavity (inside the belly where the intestines, major blood vessels, and ureters are located). Thus, the complications of laparoscopic prostatectomy are often more serious, and studies have shown that the recovery time is the same for the laparoscopic and open surgical approaches. Laparoscopic and robotic prostatectomy is difficult to learn and requires special training to perform the operation successfully; meaning to have a better outcome you need a highly qualified and trained surgeon.
Long-term outcomes of laparoscopic or robotic prostatectomy are not yet available as they are for open prostatectomy, and it is uncertain whether the simultaneous preservation of potency and continence with complete removal of the cancer can be achieved as consistently as with the classic radical retropubic prostatectomy. Recent studies have suggested that cancer recurrences rates are higher, urinary continence rates are lower, and patient satisfaction are significantly less with laparoscopic and robotic surgery.

After the prostate has been removed and the urinary tract and the bladder have been reconstructed; a urinary catheter is passed through the urethra into the bladder to drain the urine while the new connection between the bladder and urethra (called the "anastomosis") heals. The catheter will remain in place for one to two weeks after the surgery.
One or two suction drains are left beside the bladder, deep in the pelvic cavity, and brought out through the lower abdomen to drain any fluid that might accumulate in the surgical wound. They help to decrease the risk of infection and pressure from fluid in the operated area. The drains are usually removed before you are discharged from the hospital.
Most people do not pass flatus (intestinal gas) for one to two days and do not have a bowel movement until the third day after surgery, depending on how much narcotic pain medication they have had.

The goal during the first few days after your operation will be to prevent the breathing and circulation problems that can develop after any surgery. You must walk at least 100 yards three to four times a day to help your breathing and circulation.
The catheter is removed on a return visit to the surgeon's clinic, and exercises to strengthen the urinary control valve (called Kegel exercises) are begun by the patient after the catheter has been removed.
The surgeon reviews the final pathology report of the removed prostate and (if applicable) the lymph nodes. Based on this "final pathology," a follow-up plan is developed. If the pathology report is favorable, the follow-up plan entails regular visits to a physician and a regular PSA test (every 6-12 months). The post-operative PSA level should be in the "undetectable" range (less than 0.1 ng/mL).
If the pathology report shows adverse features (e.g., cancer at the surgical margin or spread of cancer through the capsule of the prostate into the surrounding tissues, seminal vesicles, or lymph nodes) additional therapy may be recommended or at least considered as an option. This may include postoperative radiation therapy and/or hormone treatment beginning 2 to 4 months after surgery.

There is a risk of developing curvature of the penis (Peyronie's disease) due to scarring from repeatedly injecting into the same site or from kinking or buckling of the penis while having intercourse without a sufficiently rigid erection.
The ability to experience climax (orgasm) is not lost after radical prostatectomy, even in the absence of an erection. However, with orgasm, there is very little (if any) ejaculate (usually some lubricating mucus from urethral glands, and sometimes urine, if urinary sphincter functions, has not fully recovered).
Because the prostate and seminal vesicles have been removed and the vas deferens has been divided, the patient is no longer able to initiate a pregnancy through sexual intercourse (but fertility is still possible through artificial insemination techniques).

Erection of the penis occurs because of the stimulation through the nerves that run adjacent to the prostate and send signals to dilate the blood vessels in the penis, allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run only a few millimeters away from the area where prostate cancer most commonly arises. Although preserving these nerves at the time of surgery is usually possible, it is not always wise. The less tissue removed around the prostate, the greater the chance cancer cells will remain. Since the primary goal of all prostate surgeries is to remove the cancer, often one or both of these nerves are completely or partially destroyed. Unless both nerves are sacrificed, the chance of recovering erectile function exists, but recovery may be slow. The average time until recovery of erections sufficient for intercourse is 4 to 24 months, but in some men, it takes longer.

Of course, the operation does not make erections better than they were before surgery, even if both nerves are spared. Even with full recovery, most men find the erections are less rigid and durable than before surgery. Younger men recover sooner, and those with stronger erections before the operation have a better chance of recovery than if the erections were weak preoperatively.
Erectile rehabilitation programs are usually encouraged beginning after surgery. There also many post-operative treatments that can help erectile dysfunction such as:
o pills,
o vacuum pumps,
o urethral suppositories,
o penile injections;
o surgical implantation of a penile prosthesis

However, these treatments do have some side effects. In general, pills are not very effective until spontaneous erections begin to return. Vacuum pumps draw blood from the veins rather than the arteries into the penis and therefore provide less oxygenation to the tissues. Intraurethral suppositories may be inefficiently absorbed through the urethra and sometimes cause urethral burning. Intracavenosal injections of vasodilators usually provide immediate rigid erections with well-oxygenated arterial blood, but if too large a dose is given, it might induce an erection that will not go away (priapism) and require a visit to the emergency room for treatment.

The time varies, but usually it is between three to six weeks.

Not with absolute certainty. The likelihood of cure varies, depending on the severity of the cancer removed. In general, one must have PSA test values of less than 0.1 ng/ml for 10 years before cure is virtually certain.

That depends mostly on the surgeon and his/her experience. Nevertheless, age and your current level of continence and potency are also key factors. Usually, incontinence is temporary and does not last long although it can persist for as much as six to twelve months. With more experienced surgeons, the risk of permanent incontinence is rare after prostate cancer surgery.

Radiotherapy for prostate cancer can be divided into two types:
external beam radiation therapy
brachytherapy

External beam radiotherapy is when a small amount of radiation is delivered in daily increments to the prostate, over a course of 7 to 8 weeks. Currently, three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) is used to deliver high-dose radiation to the prostate while minimizing the damage to the surrounding normal structures such as the bladder and rectum.
Prostate brachytherapy is a radiation technique in which radioactive seeds are implanted directly into the prostate. The seeds are delivered through the perineal skin into the prostate using needles that are inserted into the prostate using ultrasound guidance. Both low-dose rate (but high-dose) permanent prostate seeds and high dose rate (HDR) temporary implants can be used to treat the gland successfully. Prostate brachytherapy is typically performed in an outpatient setting under either general or regional anesthesia. The procedure is usually well tolerated with a low risk of surgical complications.

The relative effectiveness of external beam radiation and brachytherapy appear to be similar for early stage prostate cancer. Some patients are offered the combination therapy in which both external beam radiation and brachytherapy are utilized. For men with locally advanced cancer and/or aggressive (e.g., Gleason score of 7 or more) cancer, androgen deprivation is also added to improve cancer control.

For more information on advanced prostate cancer and its treatments please refer to our advanced prostate cancer information: Advanced Prostate Cancer
The main side effects of radiotherapy include bladder and rectal toxicities, which can result in urinary and bowel dysfunction. Erectile dysfunction is also common and appears to increase with time after treatment. The long-term effects of radiation to normal tissues remain unknown although men who elect this treatment do have a higher risk of recurrence.

Cryoablation for prostate cancer involves the controlled freezing of the prostate gland in order to destroy cancerous cells. Cryotherapy is administered in a manner similar to that of prostate brachytherapy. Special needles called "cryoprobes" are placed into the prostate transperineally under the guidance of transrectal ultrasound. Argon gas is then used to create an "iceball" which results in cell death within the predefined area. Real-time ultrasound monitoring of cryoablation combined with the use of thermocouples reduces the risk of injury to the surrounding normal tissues.

Cryoablation however is not cancer specific, and the treatment will affect all of the cells that are in the targeted area. The damage caused by freezing occurs at several levels: molecular, cellular and whole tissue structure. In particular, cryotherapy kills targeted tissue by three modes of cell death: (1) cell trauma (secondary to intracellular ice formation), (2) necrosis (immediate cell death and delayed death secondary to vascular stasis preventing oxygen to tissues), and (3) apoptosis (programmed cell death). In addition, there may be an immunological effect when the cancerous cells are killed. Important factors influencing freezing injury are the rate of temperature reduction after the initiation of freezing, the end-temperature reached and performing two freeze-thaw cycles.

The cells are not the only structures damaged during freezing. During cryoablation of the prostate, the surrounding connective tissue (stroma) and the smallest blood vessels (capillaries) are damaged and subsequently have an inadequate blood supply that is also believed to eradicate cancer.

Suitable candidates for this procedure are patients who have organ-confined prostate cancer or those who have minimal spreading beyond the prostate (clinical stage up to T3a). This includes patients undergoing prostate cancer treatment for the first time and those with recurrent cancer following radiation treatment (external beam or brachytherapy). One benefit of cryotherapy is that it is equally effective when ablating (removing) cancers of any Gleason grade. Due to the ability to use smaller needles, it may be possible to eradicate an area of the prostate that contains the cancer rather than treating the entire prostate gland. This new form of focal cryotherapy is emerging and may change the way that prostate cancer is treated in the future.

Under anesthesia (either general or spinal), an ultrasound probe is guided into the rectum. The prostate is imaged and its dimensions measured. An aiming grid software program is then activated and images of the prostate are projected on a screen. Under continuous monitoring with ultrasound imaging, cryoablation probes or needles are placed at predetermined sites within the prostate. Each of the commercially available cryosurgical systems has a different type of probe and placement strategy, but all aim to freeze the prostate, tumor(s) and surrounding tissue—except the urethral area. A urethral warming catheter is used to keep the urethra warm through the procedure. It is kept active for about 20 minutes after the final thaw cycle to prevent the urethra from freezing. In addition to the freezing probes, small temperature probes are also placed in and around the gland to monitor the temperature of the rectal wall as well as other sites such as the urinary sphincter. This has led to a dramatic reduction in side effects such as urinary incontinence and rectal fistula formation.

Prior to the freezing process, cystoscopy (direct visual inspection of the bladder using a small telescope) is performed to ensure cryoprobes have not inadvertently pierced the urethra, if so the probes are simply repositioned. A commercially available urethral warming catheter is placed at this time thereby protecting the urethra from freezing. This is important, as it minimizes the risk of urethral damage, obstruction and urinary incontinence.
Freezing starts at the anterior part of the prostate by activating the anterior probes, followed by the middle and finally the posterior probes. This sequence allows continuous monitoring (by visualizing the freezing process through the transrectal ultrasound) and sculpting of the ice balls. The physician knows when to stop freezing using both the ultrasound image as a guide as well as monitoring the temperature probes. Two freezing cycles are usually done. Between them, the prostate is allowed to thaw passively or actively either using helium or argon gas. If the prostate is longer than the active portion of the cryotherapy probe, an apical pullback maneuver is usually done to freeze the apex of the prostate. Double freezing is performed again. Following the final thaw, either a urethral Foley catheter or a suprapubic catheter (a small tube that is pierced into the bladder through a small opening in the lower abdomen) is inserted and secured in place. The physician will typically remove this catheter several days after cryotherapy when the patient is able to urinate. For most cases, the procedure can be performed under 2 hours.

A PSA test is usually done at three months. In addition, a prostatic biopsy may be recommended some time after the procedure to assess for prostate destruction and absence of viable cancer cells especially if PSA level continues to climb. Once the PSA level has stabilized, the PSA may be checked every 6 months or annually. Of course, if the PSA level is in a state of flux, it will likely be monitored more closely by your physician

Cryoablation of the prostate is currently an outpatient procedure. The patient is usually discharged from the recovery room with either a urethral catheter or a suprapubic tube in place for drainage.
Prostate cryoablation will cause the prostate to swell in the short term. Once the swelling has resolved, typically several days to a few weeks after the procedure, the urinary catheter may be removed. The patient has to demonstrate that he is capable of urinating on his own, or the catheter may need to be reinserted again until the prostate swelling has had sufficient time to resolve. Most patients are able to urinate in about 5 to 15 days but some may require longer recovery periods. Oral antibiotics and other medications that help with urination or reduce catheter irritation may be given after treatment, depending on physician preference.
New technological advances have resulted in a significant reduction of the rate of complications. An improved FDA-approved urethral warming device has minimized urethral complications. Better spacing of the probes now contributes to the effectiveness and safety of the procedure. Improved monitoring of the freezing with real-time transrectal ultrasound and temperature thermisters has given the treating physician control over the size and shape of the ice balls formed.

However, some risks still exist. Perhaps one of the most critical is the risk of urinary rectal fistula, which creates a channel between the urethra and the rectum and may cause diarrhea due to urine in the rectum and possibly severe infection due to bacteria in the bladder. However, this has largely been a complication using older technology and is rarely seen today. In fact, a recent study that included over 1000 patients in the COLD registry (CryoOn Line Database) revealed that the rectal fistula rate was only 0.4%. There is also a high incidence of erectile dysfunction when freezing the entire prostate. However, several physicians have developed methods to better preserve erections in those patients who are candidates for a nerve-preserving procedure. Other complications, although uncommon given technological advances, include urinary incontinence, urinary retention requiring transurethral resection of the prostate (TURP) and inflammation of the testicle. Almost all patients have a temporary need for a catheter to empty the bladder for several days after the procedure. Permanent, severe incontinence is rare (approximately 1 percent) and other rare complications include prostatic abscess and permanent penile numbness.

Other less common side effects that the patient may experience are scrotal swelling, numbness at the tip of the penis, passage of flecks of tissue, pain or burning sensation during urination and increased urinary frequency and/or urgency. Most men are pleasantly surprised that there is little to no pain after treatment, and recovery to normal health typically occurs within that first week. Of course, the most common symptoms that a man may experience are those related to having a catheter: urinary urgency and a minor amount of blood in the urine.

Cryoablation therapy offers:
• a minimally invasive, outpatient procedure
• favorable success rate
• low toxicity profile (complication rate)
• high quality of life
• a short recuperation period
• No blood transfusions
• Minimal anesthesia
• can be effectively used for high grade cancers
• the ice can be extended beyond the confines of the prostate to achieve an adequate margin
• prostate cancer resistant to radiation, hormones or chemotherapy may be vulnerable to the physical trauma of ice
• may be used as primary treatment or in those who have failed radiation treatment
• procedure can be repeated if the first cryoablation has not completed killed the cancer
• radiation therapy, radical prostatectomy, or hormonal therapy are still options if the procedure fails
• less than half the cost of the traditional treatment

The disadvantages are:
• extensive experience and training by the surgeon are required
• long term outcomes using current technology are still needed

Is cryoablation therapy ever used after other prostate cancer treatments have been tried?
Yes, an important use of cryoablation therapy is for patients who fail or develop recurrence after radiation therapy (external beam or brachytherapy).