BlueCross and BlueShield of Montana Medical Policy/Codes
Cryosurgical Ablation of the Prostate
Chapter: Surgery: Procedures
Current Effective Date: July 18, 2013
Original Effective Date: October 20, 2010
Publish Date: July 18, 2013
Revised Dates: June 12, 2012; April 10, 2013
Description

Cryosurgical ablation, also known as cryotherapy or cryosurgery, of prostate cancer is a technique in which cryoprobes are inserted percutaneously into the prostate gland to rapidly freeze and thaw tissue causing necrosis.  While most studies use total cryoablation, subtotal cryoablation is an emerging technique.

Cryosurgical ablation is one of several methods available to treat clinically localized prostate cancer, and may be considered an alternative to radical prostatectomy or radiation therapy.  It also may be used for salvage of non-metastatic relapse following initial therapy for clinically localized disease.  Cryosurgical ablation is less invasive than surgery and recovery time may be shorter.  While external-beam radiation therapy requires multiple treatments, typically only one treatment is required for cryoablation.

Subtotal prostate cryosurgical ablation is also being evaluated as a form of more localized therapy (referred to by some as “male lumpectomy”) for small localized prostate cancers.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Medically Necessary

BCBSMT may consider cryosurgical ablation of the prostate medically necessary as treatment of clinically localized (organ-confined) prostate cancer when performed as:

  • Initial treatment; OR
  • Salvage treatment of disease that recurs following radiation therapy.

Investigational

BCBSMT considers subtotal cryoablation of the prostate experimental, investigational and unproven in the treatment of prostate cancer.

Rationale

Cryosurgical ablation for treatment of prostate cancer has been demonstrated to be a safe and effective treatment modality for clinically localized prostate cancer.  Data from many small non-randomized uncontrolled trials have established that cryosurgical ablation of prostate tumors demonstrates similar complication rates in terms of erectile dysfunction, obstruction, incontinence, and urethral stricture as does EBRT.  The efficacy of cryoablation, as noted by post-operative biopsy results and recurrence rates, is similar to external beam radiation when treating prostate cancer.  While the data supporting this procedure for use as a salvage technique is not extensive, there is data to demonstrate that this is a useful and safe therapeutic modality for patients who have previously failed radiation therapy.  The level of evidence supporting this conclusion includes multiple case series studies.

Published studies have demonstrated that patients with low volume, localized, primary prostate cancer undergoing cryosurgery remain biochemically disease-free up to three years.  Surgically related morbidities of cryosurgery of the prostate have compared favorably to those reported for radical prostatectomy and radiation therapy.  The available data suggests that select patients with radio resistant cancer have benefited from the use of cryosurgery as a salvage therapy.  To date, case studies indicate that at least, in the short-term, cryosurgery is better tolerated than open salvage surgery and can be considered a treatment option for men who would not be candidates for open surgery.  Complication rates can be minimized through improvements in technique, instrumentation and utilization of experienced cryosurgeons.

Long et al. reported on the experience of five institutions with the use of cryoablation.  The results were compared to those of conformal radiotherapy and brachytherapy.  Patients with a previous history of failed radiotherapy were excluded and androgen deprivation was determined and categorized separately.  Patients were classified as low risk, moderate risk or high risk according to the cancer characteristics (stage of the disease, Gleason grade and prostate-specific antigen [PSA] level).  The procedure was not consistent at all institutions.  Differences included the number of probes used, number of freeze cycles per patient, length of apical pullback maneuver, real-time monitoring during freezing and the system used for freezing.  A total of 975 patients were studied, of whom 238 were low risk, 321 were moderate risk and 385 were high risk; risk was not determined in 38 patients.  The five-year rate for non-rising postoperative PSA levels for low and medium risk patients ranged between 60 and 76 percent and for high-risk patients it was 41 percent.  Only about 18 percent of the patients were found to have a positive biopsy following the procedure.

Another study by Long et al. presented a retrospective comparison of data from the cancer of the prostate strategic urologic research endeavor (CaPSURE™) database, a longitudinal observational database of patients with prostate cancer.  Adjusted overall rates of second treatment indicate that patients receiving cryoablation are 1.9 times more likely to have a second treatment than those patients who received radical prostatectomy, and 1.4 times more likely than those patients who received EBRT.  When rates of second treatment were stratified by various parameters of disease severity, the rates for cryoablation compared to radical prostatectomy tend to be significantly increased for low-risk disease but not for high-risk disease.  The same is true for EBRT compared to radical prostatectomy, but to a lesser extent.  Thus, these results do not suggest an advantage for cryoablation, and may indicate poorer outcomes for low-risk disease.

Perioperative mortality and acute life-threatening consequences of cryoablation appear to be negligible.  Patients have the highest likelihood of impotence after cryoablation, compared to radical prostatectomy or three-dimensional conformal radiation therapy (3DCRT).  The occurrence of incontinence appears comparable to 3DCRT and potentially less than radical prostatectomy.  However, other genitourinary complications are peculiar to cryoablation.  The adverse gastrointestinal consequences typical of 3DCRT are not noted after cryoablation. 

Bahn et al. reported on a large single institution retrospective long-term experience with targeted cryoablation of the prostate (TCAP).  A series of 590 consecutive patients underwent TCAP as primary therapy with curative intent for localized or locally advanced prostate cancer from March 1993 to September 2001.  After a mean follow-up time of 5.43 years the rates of morbidity were modest, and no serious complications were observed.  TCAP was shown to equal or surpass the outcome data of EBRT, three-dimensional conformal radiation, and brachytherapy. These seven-year outcome data provide compelling validation of TCAP as an efficacious treatment modality for locally confined and locally advanced prostatic carcinoma.

2009 Update

Chin and colleagues recently reported on a randomized trial of cryoablation (CRYO) compared to EBRT in patients with clinical stage T2C-T3B prostate cancer.  These patients had node-negative disease and also received six months of hormonal therapy, starting three months before treatment.  Only 64 of the planned 150 patients were accrued, entry was limited due to changes in practice and difficulty beginning cryosurgery at one of the sites.  Twenty-one of 33 (64%) in the CRYO group and 14 of 31 (45%) in the EBRT-treated group were classified as treatment failure. The mean biochemical disease-free survival (bDFS) was 41 months for the EBRT group compared to 28 months for the CRYO group. The four-year bDFS for EBRT and CRYO groups were 47 and 13%, respectively.  Disease-specific survival (DSS) and overall survival (OS) for both groups were very similar.  Serious complications were uncommon in either group.  EBRT patients exhibited adverse gastrointestinal (GI) effects more frequently.  The authors concluded that taking into account the relative deficiency in numbers and the original trial design, this prospective randomized trial indicated that the results of CRYO were less favorable compared to those of EBRT and that CRYO was suboptimal primary therapy in locally advanced prostate cancer.

Aus recently commented that cryosurgical ablation is now using third-generation equipment and that long-term follow-up from these devices, which emerged around 2000, will be needed.  These newer devices use more probes and argon gas (as opposed to liquid nitrogen) and create smaller ice balls.  Finally, there is minimal evidence for use of a newer technique of subtotal prostate cryosurgery for treatment of localized disease.

Recent studies have described results from using cryosurgery for patients with recurrent, localized prostate cancer following a course of radiation therapy.  Ng and colleagues reported on a series of 187 patients with locally recurrent prostate cancer after radiotherapy that underwent salvage cryoablation of the prostate, and were studied after a mean follow-up of 39 months.  Serum PSA at cryoablation was a predictive factor for biochemical recurrence on univariate and multivariate analysis (p <0.001).  Patients with a pre-cryoablation PSA value less than 4 ng/ml had a 5- and 8-year biochemical recurrence-free survival of 56% and 37%, respectively.  In contrast, patients with a pre-cryoablation PSA of 10 ng/ml or greater had a 5- and 8-year biochemical recurrence-free survival of only 1% and 7%, respectively.  Patients with a pre-cryoablation PSA in the range of four to 9.99 ng/ml had intermediate survival outcomes.  Overall 5- and 8-year survival was 97% and 92%, respectively.  The authors concluded that salvage cryoablation is a viable treatment option for patients with prostate cancer in whom radiation therapy has failed and that salvage cryoablation should be performed when the serum PSA level is still relatively low, because in these patients the procedure may potentially be curative. Similarly, Ismail and colleagues reported on 100 patients treated between May 2000 and November 2005 with CRYO for recurrent prostate cancer after radiotherapy; mean follow-up was 33.5 months.  All patients had biopsy-confirmed recurrent prostate cancer.  Biochemical recurrence-free survival (BRFS) was defined using a PSA level of <0.5 ng/mL and by applying the American Society for Therapeutic Radiology and Oncology (ASTRO) definition for biochemical failure.  Patients were stratified into three risk groups, i.e., high-risk (68 men), intermediate-risk (20 men) and low-risk (12 men).  There were no operative or cancer-related deaths; the five-year actuarial BRFS was 73%, 45%, and 11% for the low-, intermediate- and high-risk groups, respectively.  Complications included incontinence (13%), erectile dysfunction (86%), lower urinary tract symptoms (16%), prolonged perineal pain (4%), urinary retention (2%), and recto-urethral fistula (1%).  The authors concluded that salvage cryoablation is a safe and effective treatment for localized prostate cancer recurrence after radiotherapy.

While the data for treatment of recurrence after radiation therapy are also limited, these patients have few options; one option with recurrence is prostatectomy, which can be difficult in tissue that has been irradiated.  Like primary prostate cancer, when to proceed with treatment is a complex issue.  However, for patients with recurrence after radiation therapy who elect further treatment, based on the limited data available, cryosurgical treatment does appear to produce anti-tumor activity.

2011 Update

A literature search using MEDLINE was conducted through October 2011.  One randomized trial on cryotherapy for prostate cancer was identified.  Donnelly and colleagues reported on a randomized trial of 244 patients with newly diagnosed localized prostate cancer, during the period of December 1997 through February 2003, to compare cryoablation to external beam radiotherapy.  All patients began neoadjuvant antiandrogen therapy prior to local treatment and continued for a period of three through six months.  Median follow-up was 100 months.  At 36 months, the biochemical failure rate (PSA nadir + 2ng/mL) was 17.1% in the cryoablation group versus 13.2% in the radiotherapy group.  Overall survival at five years was 89.7% in the cryoablation group versus 88.3% in the radiotherapy group and did not differ statistically (p = .78).  At 36 months, radiotherapy patients had significantly more positive prostate biopsies than the cryoablation group (22 of 76 vs. 7 of 91 patients respectively [p = <.001]).  Observed failure rates at 60 months were equal in both groups but favored cryoablation at 84 months.  Twelve cryoablation patients experienced 13 grade 3 adverse events versus 16 grade 3 adverse events in 14 radiotherapy patients using National Cancer Institute of Canada Common Toxicity Criteria.  Urinary retention was the most common grade 3 adverse event in both treatment arms.  The authors indicated they were unable to establish cryoablation was noninferior to radiotherapy at 36 months due to the wide confidence interval.  However, they noted several issues which limit interpretation of the study results including the use of lower radiation dosages (68 Gy, 70 Gy and 73.5 Gy) than are common today and early trial closure due to lack of patient enrollment.

In a second article on the Donnelly study, Robinson et al. reported on quality of life outcomes in the same 244 patients.  With only a few exceptions, the authors found study participants reported quality of life at high-levels in both the cryoablation and radiotherapy treatment arms.  Acute urinary dysfunction, which eventually resolved, occurred more often with cryoablation as measured using the UCLA Prostate Cancer Index (mean urinary function in cryoablation was 69.4 vs. 90.7 in EBRT; P < .001; higher scores meaning better function and less bother).  UCLA Prostate Cancer Index sexual function decreased in both arms at three months. However, reduced sexual function was reported more in the cryoablation arm (mean cryoablation = 7.2 vs. 32.9 in EBRT; P < .001).  Decreased sexual function continued at the three-year evaluation with the mean score 15 points lower in the cryoablation group.

In one representative publication on focal therapy, Truesdale and colleagues reported on a retrospective chart review of 77 patients with unilateral prostate cancer treated with primary focal cryosurgery between 2002 and 2009.  Using D'Amico risk classifications, 44 patients were considered low-risk, 31 were intermediate-risk, and two were high-risk disease. Patients were followed for a median time of 24 months and the biochemical (PSA) progression-free survival rate was 72.7% overall.  Prostate cancer was confirmed by biopsy in 10 of 22 patients suspected of having recurrent disease (two ipsilateral, seven contralateral, and one bilateral disease).  The overall pathological progression-free survival rate was 87%.  Disease progression was correlated with pretreatment PSA levels, pretreatment Gleason scores, number of positive cores, and total tumor lengths.  Comparative data from studies with longer follow-up are needed are needed to evaluate this technology.  In another representative publication identified in the literature search, Williams and colleagues reported on a retrospective review of 176 patients receiving salvage cryotherapy for locally recurrent prostate cancer during the period of 1995 to 2004.  Patients were followed a mean of 7.46 years with 52 patients having been followed for more than ten years.  The ten-year, disease-free survival rate was 39%.  The authors found risk factors for prostate cancer recurrence following salvage cryotherapy were presalvage PSA levels, preradiation, and presalvage Gleason scores.  Early recurrence was highly predicted by PSA nadir >1.0 ng/dl after salvage cryotherapy.

www.ClinicalTrials.gov identified four studies on cryotherapy for prostate cancer.  Biochemical failure and quality of life (QOL) outcomes will be evaluated in an estimated 800 patients in the prospective, multicenter registry of salvage cryotherapy in recurrent prostate cancer (SCORE) trial (NCT00824928A).  This study began in January 2007 and is currently recruiting patients.  Two single-institution studies (NCT00774436 and NCT00877682) will evaluate the effectiveness of focal cryotherapy in clinically-localized prostate cancer in 50 and 100 patients.  These studies have completion dates of October 2011 and April 2012, respectively.  A phase 1 study on the safety of focal cryotherapy in 100 low-risk, localized prostate cancer patients is being conducted in Italy and is enrolling patients by invitation only (NCT00928603).

Technology Assessments, Guidelines and Position Statements

The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer (v.1.2011) indicate cryosurgery is appropriate for post-radiation recurrence in patients that have a positive prostate biopsy and negative studies for metastasis.  However, the NCCN guidelines indicate cryotherapy as primary therapy is not recommended.  The discussion notes that there is insufficient data available from long-term studies comparing cryotherapy with radiation and radical prostatectomy.

The 2008 American Urological Association Best Practice Statement has recognized cryoablation of the prostate as an appropriate treatment option for newly diagnosed or radiorecurrent organ-confined prostate cancer.  However, this Best Practice Statement indicates cryoablation in patients with clinical T3 disease is undetermined.  In addition, long-term results of subtotal prostate cryoablation are noted as being unavailable.

Summary

The available evidence for use of cryotherapy in the treatment of clinically localized (organ-confined) prostate cancer when performed as initial treatment or as salvage treatment of disease that recurs following radiation therapy is sufficient to demonstrate improvement in net health outcome.  This conclusion is based on the extensive data from cohort studies and clinical input including an indirect chain of evidence and the recognition that the data for this long-used technique is similar to data for a number of accepted techniques.  While the data for treatment of recurrence after radiation therapy are limited, these patients have few options; one option with recurrence is prostatectomy, which can be difficult in tissue that has been irradiated.  Like primary prostate cancer, when to proceed with treatment is a complex issue.  However, for patients with recurrence after radiation therapy who elect further treatment, based on the limited data available, cryosurgical treatment does appear to produce anti-tumor activity.  Given the lack of long-term follow-up data, including a lack of comparative studies, subtotal prostate cryoablation is considered experimental, investigational and unproven.

Coding

Disclaimer for coding information on Medical Policies           

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy.  They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers.  Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

60.62, 185, 198.82, 233.4, V10.46

ICD-10 Codes
C6, C79.82, D07.5, Z85.4, 0V500ZZ, 0V503ZZ, 0V504ZZ 
Procedural Codes: 55873
References
  1. De la Taille, A., Hayek, O., et al.  Salvage cryotherapy for recurrent prostate cancer after radiation therapy:  the Columbia experience.  Urology (2000) 55(1):79-84.
  2. Izawa, J.I., Perrotte, P., et al.  Local tumor control with salvage cryotherapy for locally recurrent prostate cancer after external beam radiotherapy.  Journal of Urology (2001 March) 165(3):867-70.
  3. Chin, J.L., Pautler, S.E., et al.  Results of salvage cryoablation of the prostate after radiation:  identifying predictors of treatment failure and complications.  Journal of Urology (2001 June) 165(6 part 1):1937-41; discussion 1941-2.
  4. Cryoablation of Clinically Localized Prostate Cancer.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2001 August 15) Surgery 7.01.79.
  5. Cryoablation of Clinically Localized Prostate Cancer.  Chicago, Illinois: Blue Cross Blue Shield Association – Technology Evaluation Center Assessment Program (2001 September) 16(6):1-39.
  6. Long, J.P., Bahn, D., et al.  Five-year retrospective, multi-institutional pooled analysis of cancer-related outcomes after cryosurgical ablation of the prostate.  Urology (2001) 57(3):518-23.
  7. Onik, G.  Image-guided prostate cryosurgery: state of the art.  Cancer Control (2001) 8(6):522-31.
  8. Ghafar, M.A., Johnson, C.W., et al.  Salvage cryotherapy using argon based system for locally recurrent prostate cancer after radiation therapy: the Columbia experience.  Journal of Urology (2001 October) 166(4):1333-7; discussion 1337-8.
  9. Donnelly, B.J., Saliken, J.C., et al.  Prospective trial of cryosurgical ablation of the prostate.  five-year results.  Urology (2002) 60(4):645-9.
  10. Katz, A.E., and M.A. Ghafar.  Selection of salvage cryotherapy patients.  Reviews in Urology (2002) (4 supplement 2):S18-23.
  11. Ellis, D.S.  Cryosurgery as primary treatment for localized prostate surgery: a community hospital experience.  Urology (2002) 60(2 supplement 1):34-9.  
  12. Izawa, J.I., Madsen, L.T., et al.  Salvage cryotherapy for recurrent prostate cancer after radiotherapy: variables affecting patient outcomes.  Journal of Clinical Oncology (2002 June 1) 20(11):2664-71.
  13. Onik, G., Narayan, P., et al.  Focal “nerve sparing” cryosurgery for treatment of primary prostate cancer:  a new approach to preserving potency.  Urology (2002 July) 60(1):109-14.
  14. Aus, G., Pilebald, E., et al.  Cryosurgical ablation of the prostate: 5-year follow-up of a prospective study.  European Urology (2002) 42(2):133-8.
  15. Bahn, D.K., Lee, F., et al.  Targeted cryoablation of the prostate: 7-year outcomes in the primary treatment of prostate cancer.  Urology (2002 August) 60(Supplement 2A):3-11.
  16. Robinson, J.W., Donnelly, B.J., et al.  Quality of life and sexuality of men with prostate cancer 3 years after cryosurgery.  Urology (2002 August) 60(Supplement 2A):12-8.
  17. Long, J.P.  Cryosurgical ablation of the prostate: current technique and clinical outcomes.  Surgical Technology International (2003):213-9.
  18. Katz, A.E., and J.C. Newcastle.  The current and potential role of cryoablation as a primary therapy for localized prostate cancer.  Current Oncology Report (2003 May) 5(3):231-8.
  19. Izawa, J.I., Morganstern, N., et al.  Incomplete glandular ablation after salvage cryotherapy for recurrent prostate cancer after radiotherapy.  International Journal of Radiation Oncology, Biology and Physics (2003 June 1) 56(2):468-72.
  20. Han, K.R., Cohen, J.K., et al.  Treatment of organ confined prostate cancer with third generation cryosurgery:  preliminary multicenter experience.  Journal of Urology (2003 October) 170 (4 part 1):1126-30.
  21. Chin, J.L., Touma, N., et al.  Serial histopathology results of salvage cryoablation for prostate cancer after radiation failure.  Journal of Urology (2003 October) 170(4 part 1):1199-202.
  22. Anastasiadis, A.G., Sachdev, R., et al.  Comparison of health-related quality of life and prostate-associated symptoms after primary and salvage cryotherapy for prostate cancer.  Journal of Cancer Research and Clinical Oncology (2003 December) 129(12):676-82.
  23. Touma, N.J., Izawa, J.I., et al.  Current status of local salvage therapies following radiation failure for prostate cancer (2005 February) 173(2):373-9.
  24. Chin, J.L., and N. Touma.  Current status of salvage cryoablation for prostate cancer following radiation failure.  Technology in Cancer Research and Treatment (2005 April) 4(2): 211-6.
  25. Prepelica, K.L., Okeke, Z., et al.  Cryosurgical ablation of the prostate:  high risk patient outcomes.  Cancer (2005 April 15)103(8): 1625-30.
  26. Gill, I.S., Remer, E.M., et al.  Renal cryoablation outcome at 3 years.  Journal of Urology (2005) 173(6):1903-7.
  27. Cryoablation of Clinically Localized Prostate Cancer.  Chicago, Illinois:  Blue Cross Blue Shield Association Medical Policy Reference Manual (2005 August 17) Surgery 7.01.79.
  28. Bahn, D.K., Silverman, P., et al.  Focal prostate cryoablation:  initial results show cancer control and potency preservation.  Journal of Endourology (2006 September) 20(9):688-92.
  29. Izawa, J.I., Busby, J.E., et al.  Histological changes in prostate biopsies after salvage cryotherapy: effect of chronology and the method of biopsy.  British Journal of Urology International (2006 September) 98(3):554-8.
  30. Robinson, J.W., Donnelly, B.J., et al.  Quality of life 2 years after salvage cryosurgery for the treatment of local recurrence of prostate cancer after radiotherapy.  Urologic Oncology (2006 November-December) 24(6):472-86.
  31. AUA Cryoablation for Prostate Cancer.  2002.  Prepared by the - American Urological Association. (Web site) : http://www.urologyhealth.org (Accessed 2006 December 5).
  32. Ng, C.K., Moussa, M., et al.  Salvage cryoablation of the prostate: follow-up and analysis of predictive factors for outcome.  Journal of Urology (2007) 178(4 pt 1):1253-7.
  33. Ismail, M., Ahmed, S., et al.  Salvage cryotherapy for recurrent prostate cancer after radiation failure: a prospective case series of the first 100 patients.  British Journal of Urology International (2007) 100(4):760-4.
  34. Best practice policy statement on cryosurgery for the treatment of localized prostate cancer. American Urological Association Education and Research, Inc. Linthicum (MD): American Urological Association Education and Research, Inc.; 2008. 50 p. Available online at: http://www.guidelines.gov .
  35. Chin, J.L., Ng, C.K., et al.  Randomized trial comparing cryoablation and external beam radiotherapy for T2C-T3B prostate cancer.  Prostate Cancer Prostatic Disease (2008) 11(1):40-5.
  36. Aus G. Cryosurgery for prostate cancer. Journal of Urology (2008) 180(5):1882-3.
  37. Wilt, T.J., Shamliyan, T., et al.  Comparative effectiveness of therapies for clinically localized prostate cancer.  Comparative Effectiveness Review No. 13.  Agency for Healthcare Research and Quality (2008 February).  (available at: http://effectivehealthcare.ahrq.gov accessed 2009 June).
  38. Donnelly BJ, Saliken JC, Brasher PM et al. A randomized trial of external beam radiotherapy versus cryoablation in patients with localized prostate cancer. Cancer 2010; 116(2):323-30.
  39. Robinson JW, Donnelly BJ, Siever JE et al. A randomized trial of external beam radiotherapy versus cryoablation in patients with localized prostate cancer: quality of life outcomes. Cancer 2009; 115(20):4695-704.
  40. Truesdale MD, Cheetham PJ, Hruby GW et al. An evaluation of patient selection criteria on predicting progression-free survival after primary focal unilateral nerve-sparing cryoablation for prostate cancer: recommendations for follow up. Cancer J 2010; 16(5):544-9.
  41. Williams AK, Martínez CH, Lu C et al. Disease-free survival following salvage cryotherapy for biopsy-proven radio-recurrent prostate cancer. Eur Urol 2010 Dec 22.
  42. National Cooperative Cancer Network. Prostate cancer. Clinical Practice Guidelines in Oncology, v.1.2011.
  43. Cryoablation of Prostate Cancer.  Chicago, Illinois:  Blue Cross Blue Shield Medical Policy Reference Manual. (2011 May)  Surgery 7.01.79.
History
April 2010  Medical Policy Physician's Advisory Committee meeting/approved 
June 2012  Policy updated with literature search; no change in policy statement. Rationale section rewritten. Reference numbers 5-6, 21, 23-24 and 30-31 added
April 2013 Policy formatting and language revised.  Policy statement unchanged.  Title changed from "Cryoablation of Prostate Cancer" to "Cryosurgical Ablation of the Prostate".
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Cryosurgical Ablation of the Prostate