A Patient’s Guide to High Intensity Focused Ultrasound ... · A Patient’s Guide to High Intensity Focused Ultrasound (HIFU) for Prostate Cancer11 After the procedure Patients

A Patient’s Guide to

High Intensity Focused

Ultrasound (HIFU) for

Prostate Cancer

Professor Stephen Langley MS FRCS(Urol)

Mr John Davies BSc FRCS(Urol)

Mr Christopher Eden MS FRCS(Urol)

Prostate Cancer Centre, Guildford

This booklet is intended to help you understand your prostate and what your operation will involve

This is a booklet for men who are either considering treatment, or arebeing treated, for prostate cancer by HIFU (High Intensity FocusedUltrasound). It also provides useful advice and information for theirfamilies. It is best read in conjunction with the more general bookletin this series, A Patient’s Guide to Prostate Cancer, which provides anoverview of the subject and introduces terms used in this booklet.This booklet may have already been given to you, or it may be viewedand downloaded from the website: www.prostatecancercentre.com

© 2005 ISBN: 1 898763 17 8

This booklet is copyright under the Berne Convention.No reproduction without permission. All rights reserved.

First published in 2005.

Written by:

Professor Stephen Langley, Mr John Davies and Mr Christopher EdenThe Prostate Cancer CentreStirling Road, Guildford, Surrey GU2 7RF

www.prostatecancercentre.comTel: 0845 370 7000 (local rate)

Contents

Published by:

Eurocommunica LimitedCaxton House, 51 Barnham Road, Barnham, West Sussex PO22 0ER

The views and opinions contained in this book are those of the authors and notnecessarily those of Eurocommunica Limited.

Introduction 1HIFU: High Intensity Focused Ultrasound 1

History of HIFU 2

The Device 3How is HIFU Performed? 5

Preparation 5

The Procedure 6

After the Procedure 11

Side-Effects with HIFU 14

Summary 16Useful Website Addresses and Support Networks 17

Introduction

A Patient’s Guide to High Intensity Focused Ultrasound (HIFU) for Prostate Cancer 1

HIFU: high intensity focusedultrasound HIFU is a procedure designed to treat localisedprostate cancer using high intensity focused

Anatomy.

Kidney

Ureter

Vas deferens

Bladder

Prostate

Urethra

Testis

Anus

Rectum

Seminalvesicle

A Patient’s Guide to High Intensity Focused Ultrasound (HIFU) for Prostate Cancer2

ultrasound (HIFU). A rectal probe generates highintensity ultrasound waves which travel through therectal wall and are focused in the prostate. Thisfocusing produces intense heat and provokes thedestruction of the tissue inside the targeted zone,with minimal effect to surrounding tissues. Thetreatment typically takes 3 hours to perform, usuallyunder a general anaesthetic. The technique is verynew in the field of prostate cancer treatments and isstill under research, with little long-term data toverify its effectiveness. However, for some patients,especially those with recurrent localised prostatecancer following radiotherapy, it may offer a usefulsecond-line option.

History of HIFUThe initial work in devising a machine that couldfocus high intensity ultrasound waves at the prostatebegan in the late 1980s, following the developmentof transrectal ultrasound probes. Much of the earlyresearch was carried out in France, and the devicereceived a CE mark approximately ten years later.Whilst further studieshave been requestedfrom America, todemonstrate theeffectiveness of thedevice before it receivesFDA approval, manypatients have alreadybeen treated in Europe. Ultrasound image of the

prostate gland.


The HIFU device consists of a number ofcomponents:

● A table for the patient to lie on during thetreatment.

● An ultrasound imaging system, which allows thevisualisation of the prostate by the urologist.

The Device

Ultrasoundprobe

● A transrectal device, consisting of the imagingprobe and the treatment transducer, which emitsthe focused ultrasound.These two elements areplaced in a latex balloon filled with cooled liquid.

● A computer, which controls and aims the highintensity beam according to the treatment planestablished by the urologist.

There are a number of devices connected to theequipment and measures taken, to ensure the


ImagingProbe

Treatmenttransducer

Latex balloon

Cooledliquid

patient’s safety and to optimise the treatment:

● Continuous control of the treatment probe’sposition in relation to the rectal wall, to avoiddamage to the rectum.

● A patient movement detector, to ensure that thepatient lies still and the prostate stays in target.

● Constant monitoring of the rectal temperature, toavoid heating and damaging the rectum.

● Constant control of the power delivered to thepatient, avoiding surges that may cause damageto structures surrounding the target zone.


PreparationYou may behospitalised theevening before theprocedure. You willbe given anenema forcolorectalpreparationapproximately twohours beforetreatment.

How is HIFU Performed?


The procedureThe treatment is performed under anaesthesia andis executed with the patient lying in a right lateralposition. Strict immobility is necessary during the

treatment, which can last at least three hours –hence the appeal of a general anaesthetic.

A probe is placed in the rectum. This probe has adual function: to provide the conventionalultrasound images of the prostate and also to emitthe high intensity ultrasound waves that willdestroy the gland.

Initially, the shape and size of the prostate arecalculated and processed as the target area to betreated. As cancerous prostate tissue typically hasthe same appearance on ultrasound as normalbenign tissue, it is not possible to accurately treatjust the cancerous parts of the gland. As theintention is to cure you of your disease, the entireprostate gland needs to be targeted and treated.


From studies in patients who have undergone aradical prostatectomy, it is clear that there arecommonly seven or more separate regions withinthe prostate gland where the cancerous tissue canbe identified.

At the point where the beam of high intensityconvergent ultrasound is focused (focal point), therapid and intense absorption of the ultrasound

First stage of HIFU: standard ultrasoundprobe to assess size and location of theprostate.

Catheter

Cancerousareas within

prostate

Rectal probe instandardultrasoundpicture mode

energy creates a sudden elevation of thetemperature to 100°C, which destroys the cellslocated in the targeted zone.


The targeted zone destroyed by each pulse is oval-shaped and measures up to 24mm in height by lessthan 2mm in diameter. By repeating the pulses, andmoving the focal point between each pulse, it ispossible to destroy the prostate gland. Little damageoccurs to the rectal wall by these pulses, as thebeam is not focused on this tissue.

Second stage of HIFU: transducer produceshigh intensity ultrasound, focused on thearea of the prostate being treated.

Rectal probe intherapeutictreatment mode

Tissuedestruction byHIFU


The treatment duration varies according to theprostate volume and may take approximately 3 hours.

Swelling of the prostate appears immediately afterthe treatment, due to the effective burning of thegland. This swelling or oedema compresses theurethra and can make it difficult or impossible to passurine initially. A temporary urinary catheter is insertedinto the bladder, either through the urethra (waterpipe) or through the lower abdomen (supra pubic).This allows the elimination of urine until the oedemarecedes, which generally takes 3-8 days.

Sometimes, for larger prostate glands, as well as tohelp reduce the need for prolonged post-treatmentcatheterisation, a ‘mini’ transurethral resection of theprostate, or TURP, can be done before orimmediately after the treatment with HIFU (during

Movement and focusing ofthe transducer.


the same anaesthesia). This procedure removes thecentral, obstructing portion of the prostate and ismost commonly performed in men with benignlyenlarged glands, to improve their urinary symptoms.

Such a dual procedure is mainly performed withHIFU in patients presenting with signs of prostaticobstruction (weak urinary stream, frequent nocturnalurination, residual urine volume in the bladder).Naturally, combining treatments can increase thepost-operative complications. In particular, a TURP willusually affect the ejaculatory function of the patient,causing the ejaculate to enter the bladder at the pointof orgasm, rather than being produced from thepenis. The ability to obtain an erection can alsooccasionally be affected. For more information onTURP, please read A Patient’s Guide to TURP – YourProstate Operation, which should be available at yourhospital or may be viewed and downloaded fromthe internet at: www.prostatecancercentre.com

TURP. a) before operation.b) removal of obstructing tissue, using a hot wire loop.

b)a)


✗ ✗

After the procedurePatients are normally able to eat and drink by theevening of the treatment day, and the urinarycatheter is generally removed 3-4 days after thesession. Discharge from hospital usually takes placethe day after the urinary catheter removal, onceyour doctor is happy that you are reliably able toempty your bladder. Occasionally, patients can gohome with a catheter in place, to return for itsremoval at a later date.

A prophylactic antibiotic, such as ciprofloxacin,may be prescribed for the following few weeks, toprevent the occurrence of a urinary infection.

During this period, you might experience somediscomfort, mild bleeding in the beginning of passingurine, frequent and sometimes urgent urination andurine leakage or incontinence with exertion. Over thenext few weeks, necrotic debris from the prostatewill be passed in the urine. If debris or blood areseen in the urine, it is important to maintain a highfluid intake. Caffeinated drinks should be avoided, asthey may increase urinary frequency or urgency.


Infections with fever are rare, but possible, and ifyou feel generally unwell, you should contact yourdoctor immediately for an appropriate antibiotic.

Follow-up visits after the treatmentSome 3-6 months after your treatment, controlbiopsies may be performed under local anesthesia:if they are negative, regular checking of your PSAevery three months for the first year, then six-monthlythereafter, is sufficient.

If a residual cancerous zone is detected on biopsy(in about 10% of cases), a second treatment can beconducted 6 months after the initial session, or analternative therapy may be considered.


If the biopsies are negative, butyour PSA rises, imaging is required

to identify whether the prostatecancer has spread to your pelviclymph glands or your bones. Ifso, hormone therapy may be thenext treatment to consider. If thetumour appears still confined toyour prostate, external beamradiotherapy or prostatecryotherapy may be treatmentoptions, if they have not beenused previously. However, asmany urologists feel that HIFUshould only be used in patientswho have failed an initial first-line therapy such as prostatebrachytherapy or radiotherapy,your individual treatment historywill affect the options available.

For more information onexternal beam radiotherapy,prostate cryotherapy orbrachytherapy, please read APatient’s Guide to External BeamRadiotherapy, A Patient’s Guide toProstate Cancer, A Patient’s Guideto Cryotherapy, and/or A Patient’sGuide to Prostate Brachytherapy,which should all be available atyour hospital or may be viewedand downloaded from theinternet at:www.prostatecancercentre.com

Radiotherapy.

Cryotherapy.

Wholebodybonescan,showingcancers(black)that havespread tothebones.


Side-effects with HIFUThe main side-effects with HIFU, when used to curepatients with prostate cancer, are as follows:

● Difficulty in passing urine, which requires allpatients to be initially catheterised following thetreatment, before the swollen prostate reduces insize, which may take a week or more.

● Urinary frequency, urgency and burning, whichmay be aggravated by drinking caffeinated drinkspost-procedure.

● Rectal burning and bleeding, which is mostcommon in patients treated with multiple HIFUsessions.

● Urinary leakage or incontinence occurring withphysical exertion is seen in 1 in 20 patients, butwill often settle in time with the help of pelvicfloor exercises.

● Impotence (the inability to get anerection), which is a common side-effect in HIFU patients, occurring inmore than 70% of cases, as the tinynerves supplying the erectile tissuesof the penis lie on the outer surface ofthe prostate gland and may be damagedduring treatment.

● When a TURP is performed in conjunction withHIFU, patients will normally experience a


retrograde or internal ejaculation at the time oforgasm, as the part of the prostate that is removedcauses the ejaculate to be released into thebladder, rather than being produced from thepenis. This effect is usually permanent, but is notharmful.

Who is best treated by HIFU?Due to the lack of long-term clinical data regardingthe effectiveness of HIFU in the treatment ofprostate cancer, many urologists believe that HIFUshould not be used as a first-line option. Indeed,due to this lack of data, the treatment has not yetreceived a licence to be offered in the USA.Currently, existing treatments, such as radicalprostatectomy and brachytherapy, have a proveneffectiveness and appear to offer higher chances oflong-term cure, with better side-effect profiles.However, clinical trials have begun in Europe, whichwill hopefully demonstrate the value of HIFU.

HIFU is only an option for localised prostate cancer(Stage 1 or 2), as little of the surrounding tissue is

Stage 1 cancer in prostate. Stage 2 cancer in prostate.


treated. It may be best reserved for patients whohave already been treated by either radiotherapy orcryotherapy, in whom the cancer has recurredwithin the gland.

Researchers are investigating whether treating justpart of the prostate, rather than the whole gland,may be effective in suppressing the disease andPSA, even though it is known that the cancer isnormally multifocal and spread through theprostate at the time of diagnosis. The thoughtbehind such a treatment strategy is that multiplefurther treatments in the future can be given if andwhen required. Such an untested approach to thetreatment of prostate cancer should be regardedwith caution, as the risk of significant side-effectsincreases with multiple HIFU sessions, and thechance of the cancer spreading from the prostatebetween treatments remains a real possibility.

HIFU is a novel therapy, using complex computer-assisted equipment to treat prostate cancer. Itusually requires a 2-3 hour anaesthetic to perform,and patients are catheterised for a short while aftertreatment. Whilst the science and concept isinviting, detailed studies have yet to show its long-term effectiveness, which is critical in assessing aprostate cancer treatment, and the side-effectsassociated with this treatment can be significant.

Summary

CancerBACUP www.cancerbacup.org.uk‘Helping people live with cancer.’

CancerSupport UK www.cancersupportuk.nhs.uk‘Coping with cancer at home.’

PCaSO www.pcaso.com ‘To improve the diagnosis, treatment, care and support to those troubled by this cancer.’

The Continence Foundation www.continence-foundation.org.uk‘For people with bladder and bowel problems.’

The Prostate Cancer Charity www.prostate-cancer.org.uk‘Prostate cancer is our sole concern.’

The Sexual Dysfunction Association www.impotence.org.uk‘To help sufferers of impotence (erectile dysfunction) and their partners.’

The Prostate Cancer Centre www.prostatecancercentre.com‘Providing a single point of referral to specialists at the forefront of the treatment of localisedprostate cancer.’Mr John Davies - Cryotherapy and high intensity focused ultrasound (HIFU).Mr Christopher Eden - Laparoscopic radical prostatectomy.Professor Stephen Langley - Brachytherapy.

The Prostate Project www.prostateproject.org‘A local charity promoting male health.’

Useful website addresses and support networks


Date of preparation: July 2005

A Patient’s Guide to High Intensity Focused Ultrasound ... · A Patient’s Guide to High Intensity Focused Ultrasound (HIFU) for Prostate Cancer11 After the procedure Patients

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