Am I a candidate for HIFU for my prostate cancer?

Prostate cancer is one of the leading causes of cancer-related death in men. High-intensity focused ultrasound is a new option that is FDA-approved for prostate ablation. Deciding how to treat prostate cancer with minimal lifestyle impact is a personal decision between the patient, family, and urologist.

What is HIFU?

HIFU stands for High Intensity Focused Ultrasound. Ultrasound technology uses focused beams of sound waves; many patients are familiar with having an ultrasound for pregnancy or medical tests. A HIFU treatment using ultrasound technology works much the same way. We use an ultrasound probe inserted through the rectum to focus sound waves that generate heat onto the cancerous portions of the prostate gland. This cutting-edge prostate cancer treatment was recently approved by the FDA for the ablation of prostate tissue.

Am I a Good Candidate for HIFU Prostate Cancer Treatment?

Typically, patients who have small prostates and small amounts of cancer are good candidates. HIFU works by sending energy that “melts” or coagulates cancer tissue. This energy is sent to a very focused area of the prostate while the surgeon uses ultrasound images to view the tissue being treated. The junction between the prostate and the urethra, called the prostate apex ,is a difficult area to distinguish using ultrasound. Therefore, cancer in this area can be challenging to treat.

How do I know if my prostate is too big for HIFU?

HIFU of the prostate

In one of the FDA studies, prostates over 40 grams in size were considered too big for HIFU. Larger prostates increase the risk of urinary problems after the procedure. One such problem includes urinary strictures, which can be an unexpected and frustrating side effect of HIFU treatment. Patients with urinary strictures cannot urinate because the urethra becomes blocked by scar tissue. In such cases, the surgeon may need to do follow up procedures to open the urethra.

In addition, the focus beam of treatment may not reach all areas of an enlarged prostate, which creates the possibility of inadequate cancer treatment. This would result in a PSA level that is elevated even after the procedure. Understanding what to do with a rising PSA can be difficult and the doctor may suggest a repeat biopsy.

Can anything be done to make my prostate smaller for HIFU?

Surgery and medication are two ways to potentially decrease prostate size.
Surgery for enlarged prostate is done when patients are having problems urinating. Imagine a donut representing the prostate. As the prostate grows bigger the donut hole gets smaller, constricting urinary flow. Symptoms include slow flow, hesitancy, dribbling, and urgency. Surgery can open the donut hole; however, the outside dimensions of the prostate stay about the same. HIFU may still have problems reaching the entire prostate.

Medication to shrink the prostate can be effective. Usually, a hormone shot is given. The shot (LHRH agonist or LHRH antagonist ) actually turns off lutenizing hormone (LH) in the prostate, which halts testicular production of testosterone. Testosterone and its byproduct, dihydrotestosterone (5-DHT) make the prostate grow. Therefore, stopping the hormone production will shrink the prostate dramatically. In fact, halting testosterone production by surgery was the original treatment for prostate cancer. Surgical castration was a means of controlling (not curing) prostate cancer and even with the shot, not all prostates become small enough for treatment. After this procedure, there is usually a 3-4 month wait to recheck the prostate with ultrasound. On average, prostates can shrink 30-50% in size.

How successful is HIFU for prostate cancer treatment?

For small prostates with limited cancer, HIFU is typically effective. Since studies are still limited in the USA, the approval for HIFU was for ablation of prostate tissue and not specifically for cancer treatment. As a result, patients should be very committed to getting HIFU. If a patient has a higher Gleason Score cancer (a “7” or a “4+3”) or the cancer is on both sides of the prostate, very close post-procedure monitoring is necessary as studies of long-term success are unclear.

What is the surgery like for HIFU of my prostate?

HIFU surgery takes place with the patient under sedation and a spinal anesthetic. Depending on the size of the prostate, the procedure can take 1-3 hours. A tiny tube called a catheter is placed in the bladder just above the pubic bone and is left in place for a couple of weeks to allow the bladder to drain. An ultrasound probe is placed in the rectum to allow the ultrasound to image and treat the prostate tissue. Patients have little to no bleeding during the procedure; however, the HIFU treatment can cause temporary swelling of the prostate. Patients are generally able to walk out with minimal pain after the procedure.

Does HIFU affect my urinary control?

Incontinence or leakage of urine is rare after HIFU. Surgery, in contrast, will cause patients to have temporary incontinence. This usually recovers, but HIFU has the advantage because there is no initial leakage or long term leakage risk. Patients with HIFU may notice a thinner flow initially, but over time, the flow will usually be better than before. However, prostate cancer HIFU does carry the risk of scarring of the prostate urethra.  This could cause severe problems, such as the inability to urinate and empty the bladder, and risk of infection. Techniques to avoid this have been developed. One such technique spares the “donut hole” from treatment but could also skip treatment of possible areas of cancer. It is critical for the urologist to help patients understand if this procedure could work for them or not.

Will HIFU affect my sexual function?

The nerves involving sexual function surround the prostate. Nerve sparing is possible with HIFU, which minimizes transfer of heat to the nerves. Compared to surgery, recovery is usually immediate with HIFU. Nerve sparing surgery in experienced hands can dramatically improve the odds of sexual function recovery.

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