Cryotherapy is a way of treating prostate cancer that uses freezing and thawing to kill the cancer cells in the prostate gland. It is also sometimes known as cryosurgery or cryoablation. It is done using a number of thin needles (cryoneedles) which are inserted into the prostate gland under local or general anaesthetic. This process kills both cancer cells and healthy cells within the gland.

There have been improvements in cryotherapy in recent years, which have reduced the risk of side effects and improved the success of the treatment.^1,2 However, we need more research to show whether cryotherapy is as good as other treatments in the long term.³ For more
information on the side effects of cryotherapy see below.

Cryotherapy can be used to treat prostate cancer that has not spread outside the prostate gland (localised prostate cancer). It is also sometimes used to treat cancer that is breaking through the capsule of the prostate ( locally advanced prostate cancer). It is not suitable for cancer that has spread beyond the prostate gland to other parts of the body (advanced prostate cancer).

Cryotherapy is usually used for men whose prostate cancer has come back after treatment with radiotherapy or brachytherapy. (recurrent prostate cancer). It is less commonly offered as a first treatment for prostate cancer. However, it may be an option for men who are unable to have other treatments such as surgery or radiotherapy. For example men with heart problems (cardiovascular problems) may not be able to have surgery for prostate cancer.

Men with severe urinary symptoms may not be suitable for cryotherapy as it can make these problems worse. If you have difficulty passing urine or have to pass urine frequently you may wish to discuss this with your doctor before choosing a treatment.

Cryotherapy is newer than some of the other treatments for prostate cancer. We do not know as much about how effective it is in the long term, or the risk of side effects compared with other treatments.^2,3 Researchers are studying better ways of carrying out cryotherapy. Because of this, it is only available in specialist centres in the UK, or as part of a clinical trial.⁴

Your doctor or nurse should discuss all your treatment options with you. It is important that they give you information about the advantages, disadvantages and all the possible side effects of cryotherapy to help you decide whether it is right for you. Your options will depend on whether you have just been diagnosed, or if the cancer has come back after
previous treatment.

Other first treatment options for localised prostate cancer may include:
• Active surveillance
• Surgery to remove the prostate (radical prostatectomy)
• External beam radiotherapy (EBRT), or
• Brachytherapy (a type of radiotherapy)

You may also be offered high intensity focused ultrasound (HIFU). Like cryotherapy, it is not widely available in the UK and researchers are studying better ways of carrying it out. It may be available in specialist centres or as part of a clinical trial.

You can find more information about all these treatments in our treatment choices page or by calling our Specialist Nurses on our confidential helpline.

For more information about treatment options after your first treatment read our booklet, Recurrent prostate cancer: A guide to treatment and support.

The advantages and disadvantages of cryotherapy may depend on whether you are having it as a first treatment for prostate cancer or because the cancer has come back after another treatment. There is a higher risk of side effects if you have already had treatment for prostate cancer. See below for more information on side effects. You can ask your doctor or nurse if you are unsure about any of the advantages or disadvantages of cryotherapy.

Advantages

• Cryotherapy involves less invasive surgery than some other treatments, with little blood loss.
• You will only be in hospital for a short time¹ and recovery time is quick.
• Cryotherapy may be a treatment option if your cancer has come back afte radiotherapy or brachytherapy.³

Disadvantages

• Many men who have cryotherapy have long term erectile problems following treatment.⁵
• There is also a risk of other side effects which could affect your quality of life such as urinary problems and a small risk of bowel problems.⁵
• We do not know as much about how effective the treatment is in the long term (after 10 or 15 years),² compared with other treatments.
• Cryotherapy is only available in specialist centres in the UK or as part of a clinical trial.

What might be an advantage for one person may not be for someone else. Please talk to your doctor or nurse about your own situation.

Each hospital will do things slightly differently, so ask your doctor or nurse for details of how they carry out the procedure.

Before having treatment
Your doctor or nurse may ask you to take some medicine, called a laxative, to help empty your bowels immediately before treatment.⁶ This will give your doctor a good view of the prostate gland during treatment using an ultrasound probe (see below).

During treatment
Cryotherapy is usually done under general anaesthetic so that you are asleep during the treatment. It is sometimes done under local anaesthetic so that you are awake but won’t feel anything.

A tube, known as a warming catheter, is passed through your penis into your bladder. Warm liquid is circulated through the catheter during the treatment. This is to help prevent the tube which you pass urine through (your urethra) from freezing and being damaged during treatment.

An ultrasound probe is inserted into your back passage. This allows your doctor to see an image of the prostate gland and make sure the cryotherapy needles are in the right place. Several thin needles, known as cryoneedles or cryoprobes, are then inserted into the prostate gland through the skin between the testicles and back passage (perineum). Probes to monitor temperature are also inserted into and around the prostate gland.

Freezing gasses are passed down the needles, causing the temperature to drop to about –40^oC. This freezes and destroys the surrounding tissue. The prostate gland is then allowed to warm up, either naturally, or by passing a different gas through the needles to warm the gland more quickly. This is called a freeze-thaw cycle. The process of freezing and thawing is repeated. There are usually two freeze-thaw cycles but there may be more if you have a large prostate gland.⁶

The needles and probes are then removed and, after about 20 minutes, the warming catheter is also removed.⁶ Another tube, used to drain urine, will be passed into your bladder either through the penis (urethral catheter) or through a small cut in your abdomen (suprapubic catheter). This will be left in for one to two weeks⁵ after you go
home.

The whole process usually takes around two hours.

Going home after treatment
Most people can go home on the same day or the following day. It is normal to have some discomfort, and your doctor or nurse will tell you which painkillers you can take. You will be given antibiotics to reduce the risk of infection which you will need to take for a few days after you go home. If your urine starts to smell strongly or if you have a temperature contact your doctor or nurse. These could be signs of an infection and you may need more antibiotics.

You will go home with a catheter in place to avoid any problems passing urine. This will be left in for one to two weeks.⁵ Your nurse will show you how to care for the catheter before you leave the hospital. Some treatment centres may also give you medication called alpha-blockers to relax the muscle in and around the prostate to help you pass urine.

When you have your catheter removed at the hospital it may be uncomfortable, but it should not be painful. You will need to stay for a few hours after the catheter has come out to check that you can pass urine without difficulty. You may wish to take some spare underwear and spare pair of trousers with you. In some centres your doctor or nurse may arrange for you to have your catheter removed at home.

You may see some blood in your urine, both while the catheter is in and after it has come out. This is normal, and you should drink plenty of fluids to help clear the blood. If you are worried about it at all, contact your doctor or nurse for advice.

You may also have some bruising and swelling of the skin around the testicles (scrotum), buttocks and inner thigh in the few weeks after the procedure. Your doctor or nurse may advise you to avoid long periods of standing for the first few weeks. You should be able to go back to your day-to-day activities as soon as you feel able to, although it may take a few weeks or months before you feel back to normal.

What happens afterwards?
You will have follow up appointments with your doctor or nurse at the hospital to check your recovery and monitor your response to the treatment. Your prostate specific antigen (PSA) level will be monitored regularly to help check how well the treatment has worked. How often will vary depending on the treatment centre, but you should have a PSA test about every three months for at least the first year, and every six months after that. You can ask your doctor or nurse how often you will have a test.

If you had cryotherapy as a first treatment and your cancer starts to grow again, you may be able to have more cryotherapy. In some cases you may be offered radiotherapy or, rarely, surgery. If you had cryotherapy as a second treatment and your cancer starts to grow again, you may be offered hormone therapy.

You can find more information about treatment options after cancer has come back in
our booklet, Recurrent prostate cancer. A guide to treatment and support, or you can call our Specialist Nurses on our confidential helpline.

Like all treatments, cryotherapy can cause side effects. Cryotherapy will affect each man differently, and you may not get all of the side effects. The most common side effects include erection problems and urinary problems.

Many of the side effects of the treatment are caused when healthy tissues are frozen and damaged. There is a greater risk of side effects if you have already had radiotherapy or brachytherapy to treat prostate cancer. This is because these treatments may have already caused some damage to the tissues surrounding the prostate gland.⁷

Short term side effects include:

• blood in the urine (haematuria)
• difficulty or discomfort passing urine
• bruising and swelling of the penis, skin around the testicles (scrotum), inner thigh and the area between your testicles and back passage (perineum), or
• pain and bleeding where the needles were inserted.

Erectile dysfunction
The most common long term side effect is difficulty getting or keeping an erection (erectile dysfunction). This is because the nerves responsible for erections can be damaged by the treatment. More than three quarters of men (over 75 per cent) will be unable to get an erection following cryotherapy.^{1, 5, 8, 9, 10} If sex is important to you, you should discuss with your doctor or nurse whether cryotherapy is a suitable treatment for you.

Some men will find that they gradually get back their erections¹ but for most men this is likely to be a long term problem. We do not know for sure how many men will get their erections back. There are medical treatments available which may be helpful and you can discuss these with your doctor of nurse. Our page about sex and prostate cancer gives more information on treatments for erectile dysfunction.

If you are planning to father children in the future, it might be possible to store your sperm before having cryotherapy. Speak to your doctor or nurse.

Urinary problems
Cryotherapy can cause urinary problems including leaking urine (urinary incontinence) and having a weak or slow flow of urine. These problems usually improve with time.

Up to one in twenty men (five per cent) who have cryotherapy as a first treatment will find that they leak urine to some degree.^{9, 2}. This is more likely if you have cryotherapy as a second treatment⁹ and affects up to one in six men.^8,10 For some men this may improve with time. However for some men the problem will be long term and you may have to wear pads in your underwear either temporarily or permanently. Making some changes to your lifestyle, such as doing pelvic floor muscle exercises may help to improve urinary problems or make them easier to manage. You can read about these in our Tool Kit fact sheet, Pelvic floor muscle exercises.

A recent study found that about four in every hundred men who had cryotherapy as a first treatment had a weak or slow flow of urine after treatment^{9, 2}. This is more likely if cryotherapy is a second treatment, affecting up to one in five men.^8,10 The problem can be caused by swelling of the prostate gland and may pass in time.

In a small number of cases a weak or slow flow of urine can be caused by damage to the tube that carries urine out through the penis (urethra). Small pieces of dead tissue are passed through the urethra (urethral sloughing) and may cause a blockage, making it difficult or impossible to pass urine. This can affect up to three out of every 100 men (three per cent) who have cryotherapy.^{9, 2, 8} Having a catheter for a short while may ease the problem or if necessary you can have an operation to help this.

There is also a small risk that the urethra may become narrowed (stricture) after reatment. This will also cause a weak or slow flow of urine. Some men may need to have a procedure in hospital to help with this.

Speak to your doctor or nurse if you are having difficulty passing urine. There is more information on our page about urinary problems and prostate cancer.

Bowel problems
A small number of men may get a complication where a hole forms between the back passage (rectum) and the tube which carries urine through the penis (urethra). This is known as a fistula, and is rare in men having cryotherapy as a first treatment.^1,9 It is more likely, though still uncommon, if you have had an earlier treatment for prostate cancer which may have damaged the wall of the back passage. It can affect up to two out of every 100 men (up to two per cent).^9,10

Fistulas can develop up to several weeks after cryotherapy. Sometimes pain and infections of the urethra can be early signs of a fistula, although these can also be caused by something else. Contact your doctor or nurse if your urine is strong smelling or you have a temperature, which could be signs of an infection. Discharge from the urethra or back passage or diarrhoea may also be signs of a fistula. If you develop a fistula, you will need to have an operation to repair the hole.

Pain
It is normal to experience some pain or discomfort after having cryotherapy. This can be managed with pain-relieving drugs and your doctor or nurse should tell you which you can take. However some men will have pain that lasts for a few weeks or months. The pain may be in the area in or around the penis, testicles and back passage. There is a greater risk of pain if you have had another treatment before cryotherapy. Antibiotics may help and the pain will usually improve. Speak to your doctor of nurse if you have any pain.

Some specialists are looking at a new way of using cryotherapy called focal cryotherapy. This means that cryotherapy is used to treat only the areas of the prostate gland where there is cancer, rather than treating the whole gland. The aim is to avoid the side effects of cryotherapy by leaving healthy tissue unharmed. This is a new area of research and we need more information about how successful this treatment option is before it is made widely available.

As well as getting medical help to treat your cancer, you may find that it helps to talk to family or friends about how you are feeling. Sharing concerns can make any decisions about your treatment easier to deal with. You could also speak to your doctor or nurse or call our Specialist Nurses on our confidential helpline.

Partners and family also often worry about their loved one, and may find it helpful to talk to your doctor or nurse or call our cialist Specialist Nurses.

Some people find that it helps to talk to other men who have had cryotherapy. There are prostate cancer support groups throughout the country. You can ask your doctor or nurse for details, or you can see our list of support groups.

You might find it helpful to speak to someone who has been affected by prostate cancer. Our peer support volunteers are men and women who have personal experiences of prostate cancer. They are trained to listen and offer support over the telephone. Call our Specialist Nurses to be put in touch with a volunteer.

If you have access to the internet, you can sign up to our online community on our website, where you can share your views and experiences with others affected by prostate cancer. Our website address is prostatecanceruk.org.

If you would rather speak to a professional counsellor, you can ask your GP if there is one available on the NHS or you can get a list of private counsellors from The British Association of Counselling and Psychotherapy (see below).

• How successful is cryotherapy at treating prostate cancer?
• What is the risk of side effects?
• What are my other treatment options?
• How much experience does the specialist have in carrying out cryotherapy?
• How often will you check my PSA after the treatment?

The following organisations provide further information relevant to this page

British Association of Counselling and Psychotherapy (BACP)
www.itsgoodtotalk.org.uk
Telephone: 01455 883300
BACP will help you find qualified counsellors. They are happy to discuss any queries or concerns you have about choosing a counsellor or the counselling process.

CancerHelp UK
http://cancerhelp.cancerresearchuk.org/
Part of Cancer Research UK, Cancer Help provides information about all types of cancer and a database of cancer clinical trials.

Healthtalkonline
www.healthtalkonline.org
Lets you share other people's experiences of health and illness. You can watch or listen to videos of the interviews, read about people's experiences and find reliable information about conditions, treatment choices and support.

Macmillan Cancer Support
www.macmillan.org.uk
Provides practical, financial and emotional support for people with cancer, their family and friends.

National Institute for Health & Clinical Excellence (NICE)
www.nice.org.uk
Order line: 0845 003 7783
NICE produces recommendations on whether a treatment is suitable for use in the NHS.

UK Prostate Link
www.prostate-link.org.uk
UK Prostate Link helps you find and compare reliable information about all aspects of prostate cancer, including cryotherapy.

Reviewed by:

• Professor Damian Greene, Consultant Urologist, City Hospital, Sunderland
• Susan Asterling, Urology Research Nurse, Sunderland Royal Hospital
• Fiona Birrell, Cryotherapy Clinical Nurse Specialist, Gartnavel General Hospital
• Hashim Ahmed, MRC Clinical Research Fellow (Uro-Oncology), Division of Surgery and Interventional Science, University College London
• Prostate Cancer Voices
• Prostate Cancer UK Specialist Nurses

Written and edited by:
Prostate Cancer UK’s Information Team

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3. National Institute for Clinical Excellence. Prostate cancer: diagnosis and treatment. Full Guideline 2008
4. BUG, BAUS and BPG, MDT (Multi-disciplinary Team) Guidance for Managing Prostate Cancer, 2nd Edition, November 2009
5. National Institute for Clinical Excellence. Cryotherapy for recurrent prostate cancer. Interventional procedure guidance 119. 2005
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