Prostate Surgery

High-Intensity Focused Ultrasound (HIFU) for Prostate Cancer

Prostate cancer is, according to the American Cancer Society, besides skin cancer, the most common cancer in American men.

One in nine men in the United States will be diagnosed with this serious disease in his lifetime.

When caught early, it’s possible to make a full recovery as various management options are available.

One of the treatment options for this type of cancer is high-intensity focused ultrasound or HIFU.

In cases of high risk of cancer progression and treatment relapse, surgical intervention may be necessary. We generally are against any invasive surgery, but we also think our readers should be informed, which is why we would share this

What is it, and how does it works? Read on to learn more about it.

What is HIFU?

High-intensity focused ultrasound (HIFU) is a non-invasive technique that uses non-ionizing ultrasonic waves to heat tissue.

In October 2015, the FDA approved this procedure as another modality for prostate tissue ablation, but it is also used for the treatment of prostate cancer.

It is essential to mention that HIFU is still a subject of clinical trial and studies that aim to uncover its full potential, efficacy in treatment for prostate cancer.

In countries such as Canada, Mexico, and parts of Europe, HIFU has been used for treating prostate cancer for more than 20 years.

This is a promising procedure. A study published in the European Urology discovered that men with newly diagnosed, no-metastatic prostate cancer had a 5-year failure-free survival of 88% when treated with HIFU.

The same study showed that the use of HIFU to destroy prostate cancer tumors might be as effective as radiotherapy and surgery, but with a lower risk of adverse reactions.

However, some evidence also shows that long-term prostate cancer outcomes are worse with HIFU than in patients who undergo radical prostatectomy.

We can expect a lot about this procedure in renal and urology news in the near future. For instance, the procedure is also studied to uncover its efficacy in the treatment of breast cancer.

Generally speaking, this therapy is an alternative choice for localized prostate cancer and low- or medium-risk prostate cancer treatment.

It can be performed before prostatectomy, i.e., a doctor may recommend it to see how it will tackle the disease before some invasive management option.

Before we go further in the subject, it is worth noting that the doctor recommends therapy based on the stage of cancer, symptoms, and overall health condition of a man.

How is HIFU used to treat Prostate Cancer?

Although the name of the procedure seems complicated, the whole process is simple and straightforward. HIFU targets cancerous tissue and cells in the prostate gland with radiation-free sound waves.

The urologist points sound waves through the wall of the rectum, i.e., the bottom part of the large intestine.

The waves are directed at cancerous cells to break down the tumor. They do so by heating up to temperature as high as 90°F (32°C).

At that temperature, sound waves can destroy cancer cells in a matter of a few seconds only. Doctors don’t pick the direction of cancerous cells randomly; they use magnetic resonance imaging (MRI) and ultrasound imaging to detect the location of the tumor.

We can divide this procedure into two different types:

1) Whole prostate HIFU that treats the entire gland.


2) Focal HIFU that targets a smaller portion of the prostate.

Sometimes only focal HIFU is performed if the cancer is not likely to spread, in which case the doctor recommends active surveillance. That’s why the procedure is particularly useful for localized prostate cancer.

Depending on the severity of cancer, the doctor chooses the adequate type of this procedure for a specific patient. For example, one may have a whole gland HIFU, while the other patient may require focal type only.

Before treatment

It is important to get informed about every aspect of some procedure so that you can be confident in the decision whether to undergo it or not.

HIFU for prostate cancer is usually not the first choice of treatment, but an alternative option if other approaches prove to be ineffective.

For example, a doctor may recommend hormone therapy and transurethral resection of the prostate (TURP) to patients with large prostate before they recommend HIFU.

Hormone therapy is administered two to three months before HIFU for prostate cancer procedures to decrease the size of the gland and make sure the localized prostate cancer is easier to tackle.

On the other hand, TURP involves removing prostate tissue to improve urine flow. The reason why doctors may recommend TURP before this procedure is that it can decrease the risk of urinary problems after ultrasound therapy.

Men who need focal HIFU undergo screening process first. After all, the doctor needs to know in what area precisely to target the ultrasound waves. Besides MRI, some men may also need biopsy whose person is also to show the location of cancer and its stage, i.e., how likely it is to spread to nearby tissues or not.

During treatment

You are probably wondering how the whole procedure looks like. What is going on when you are undergoing HIFU?

Once the decision has been made, the doctor at the urologic oncology department will explain everything that will happen during the procedure. You will need to abstain from food and drinks at least six hours prior to the procedure.

The duration of the procedure depends on its type. Whole prostate HIFU lasts about three hours, while focal HIFU for prostate cancer is performed in one to two hours.

Prostate cancer patients usually need to go to the hospital in the morning, where they will have enema first. Enema is the liquid put inside the rectum to clear out the bowels. This will allow the doctor to perform the procedure adequately.

HIFU is performed under general anesthesia, meaning a man is asleep during the whole time. Some men may not be able to receive general anesthesia due to health concerns.

In those cases, spinal anesthetic or epidural is administered. In addition to the epidural, you may receive a sedative that will make you sleepy.

During the treatment, a man usually needs to lie on the side with knees brought in toward the chest. But, some patients can lie on the back with legs apart.

The doctor and nurses will recommend the best position before the therapy, so make sure to adhere to their instructions carefully. The catheter is also inserted before the procedure.

Once the prepping for the procedure is done, the doctor will start with the main part of the “event.”

So, to attack cancer with HIFU, the doctor inserts a transrectal probe through the rectum to release a beam of high-intensity focused ultrasound energy.

The transducer is surrounded by a cooling balloon that prevents the heating energy from affecting the rectum and nearby tissues, only to be targeted at the prostate. These waves travel through the rectal area to the prostate to tackle one part of the gland’s tissue at a time.

Once the beam is done with one part of the prostate, the doctor moves it to destroy cancer cells in the other region of the gland. The probe also takes images that doctors can examine.

After treatment

High-intensity focused ultrasound is an outpatient procedure meaning a patient gets to leave the hospital the same day.

After the procedure, you may feel pain and discomfort in testicles and rectum. To alleviate these problems, you can take a painkiller.

The doctor may prescribe antibiotics to prevent infection. A man who has undergone HIFU for prostate cancer may also need to take laxative that softens the stool and makes bowel movements easier. This will prevent pain and discomfort in the rectal area caused by passing hard stools.

Bearing in mind that HIFU tends to make prostate swell, a man experiences difficulties urinating, which is why the catheter is necessary for up to a week after the procedure. This will help avoid problems such as urinary retention.

Before a patient is released home, the healthcare provider explains what to expect, when pain and discomfort will heal, what to do with a catheter, among other things. They will schedule a follow-up appointment, and it is strongly advised to adhere to all the instructions they provide.

During the follow-up appointments, the doctor aims to determine whether cancer has responded to the treatment or if side effects occurred.

This is also a great time to ask any questions you have about cancer, the procedure, and everything you want to know about the subject.

Men who undergo HIFU will have a PSA test three to six months for the first few years after the procedure. The goal of the test is to determine if the procedure worked and how cancer responded to it.

The doctor may also recommend an MRI scan and biopsy to confirm the procedure results. Watchful waiting is employed in men who undergo focal HIFU procedure for localized prostate cancer.

What are the advantages of HIFU?

Advantages of HIFU procedure are numerous, including the following:

  • Performed in an outpatient setting

  • Short recovery time (one to two weeks)

  • Patients can undergo the procedure in the cases of recurrent prostate

  • Can be performed even if the patient underwent other treatments

What are the disadvantages of HIFU?

Despite important advantages, HIFU has some disadvantages, as well. They include:

  • Not available in all hospitals and clinics

  • Only FDA-approved for prostate ablation, but widely used for the treatment of cancer too

  • Relatively novel treatment so more research is needed to uncover all its mechanisms, safety profile, etc.

  • No real-time visualization which can be tricky because the information collected prior to the procedure is not always accurate.

  • Further clinical trials and studies are necessary to learn more about it

What are the side effects of HIFU?

Every treatment, regardless of the health condition, comes with a particular risk of side effects, and HIFU medical is not the exception.

Not every man will have adverse reactions to this ultrasound treatment. Also, those who develop side effects may experience them differently. After all, every person is different, and we experience things differently.

The most common side effects associated with this treatment are erectile dysfunction and urinary problems. A patient is more likely to experience side effects if he has undergone more than one HIFU treatment.

The risk of adverse reactions increases when a man has had other treatments for prostate cancer prior to HIFU ultrasound. Why? The other treatment may have damaged the area around the walnut-sized gland and made it vulnerable.

Generally speaking, we can divide the side effects of HIFU into two categories short- and long-term.

Short-term adverse reactions of HIFU include:

  • Blood in the urine while the catheter is in place

  • Small pieces of prostate tissue in the urine six to eight weeks after the treatment

  • Erectile dysfunction

  • Urine infections

  • Difficulty to empty the bladder

  • Infections in the testicles or tubes that carry sperm from testicles

On the other hand, long-term side effects include:

  • Sexual problems such as releasing a lower amount of semen or no semen at all, retrograde ejaculation

  • Urinary issues such as urinary incontinence, stress incontinence, increased the frequency of urination, urgent need to urinate

  • Rectal fistula or the hole between the urethra and back passage (rarely happens)

Some men may experience burning sensation when urinating, whether short- or long-term. Moreover, due to the risk of damage to tiny nerves that participate in erectile function, about 70% of men undergoing HIFU become impotent.

Conclusion

High-intensity focused ultrasound, or HIFU is a procedure used to treat prostate cancer.

Like other procedures, this one also has some risk of side effects. Consult your doctor about the procedure and its strengths and weaknesses.

Sources

  1. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
  2. https://www.onclive.com/web-exclusives/expert-discusses-optimizing-hifu-and-other-strategies-in-prostate-cancer
  3. https://www.europeanurology.com/article/S0302-2838(18)30431-7/fulltext
  4. https://www.renalandurologynews.com/home/news/urology/prostate-cancer/long-term-prostate-cancer-outcomes-worse-with-hifu-vs-rp/
  5. https://prostatecanceruk.org/prostate-information/treatments/hifu
  6. https://www.roboticoncology.com/high-intensity-focused-ultrasound-faqs/
  7. https://www.ncbi.nlm.nih.gov/m/pubmed/19260381/
  8. Huang X, Yuan F, Liang M, et al. M-HIFU inhibits tumor growth, suppresses STAT3 activity and enhances tumor specific immunity in a transplant tumor model of prostate cancer. PLoS One. 2012;7(7):e41632. doi:10.1371/journal.pone.0041632
  9. Peek MCL, Wu F. High-intensity focused ultrasound in the treatment of breast tumours. Ecancermedicalscience. 2018;12:794. Published 2018 Jan 10. doi:10.3332/ecancer.2018.794
  10. Kovatcheva R, Zaletel K, Vlahov J, Stoinov J. Long-term efficacy of ultrasound-guided high-intensity focused ultrasound treatment of breast fibroadenoma. J Ther Ultrasound. 2017;5:1. Published 2017 Mar 16. doi:10.1186/s40349-017-0083-1
  11. Jenne JW1, Preusser T, Günther M.. (2012). High-intensity focused ultrasound: principles, therapy guidance, simulations and applications.. Zeitschrift für Medizinische Physik . 22 (4), p311-22.

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