Excellent review of HIFU in contemporary urology

HIFU for prostate cancer – For more than a decade, HIFU has been investigated as a less invasive alternative to surgical treatment in men with localized prostate cancer. A growing and maturing body of research suggests that HIFU is a safe and efficacious option for several subgroups of patients. – Contemporary Urology

HIFU for prostate cancer
For more than a decade, HIFU has been investigated as a less invasive alternative to surgical treatment in men with localized prostate cancer. A growing and maturing body of research suggests that HIFU is a safe and efficacious option for several subgroups of patients.

I am still skeptical of long term cancer cures of HIFU for prostate cancer, but I expect it to be in the USA in the next 2-3 years. Reading the article shows that there have been advances since I was involved with HIFU research 6 years ago at Indiana University.
This was a good review of the current technology and side effects and early outcomes.
Important negatives that the article point out are the difficulty in treating large prostates. They recommend treating the prostate before HIFU hormones (which have side effects of hot flashes, mood swings, etc.), a TURP (which can be very bloody in large prostates, or treatment with 2 rounds of HIFU. This last option is most attractive in my opinion if you have a large prostate and elect to have HIFU.
The other negative is the use of a foley catheter (2-7 days) which is similar to my catheter length after dvP. Patients also need a suprapubic catheter which is not needed with dvP.
My last issue is the suggestion that a negative biopsy is similar to a cure. A biopsy will only sample a small part of the prostate and longer followup will be needed to see how many cancer cells will not be destroyed and lead to clinical failures.

HIFU study for prostate cancer

UroToday – High Intensity Focused Ultrasound Therapy for Clinically Localized Prostate Cancer: Efficacy and Morbidity of the Minimally Invasive Procedure
I am not personally that impressed with HIFU from what I have been reading and from my research at Indiana.
This series shows a relatively high failure rate of almost 30% and over 30% of patients having trouble with erections even though 23% of patients needed re-treatment.
My other main concern is how patients will fo after failing and needing surgery, which will be more complicated and have more side effects than primary surgery.

HIFU and cryosurgery for prostate cancer

UroToday – EAU 2007 – Minimally Invasive and Other Treatment Strategies in Localized Prostate Cancer

The authors conclude that this treatment modality is appropriate for patients with localized CaP who are not candidates for surgery. The oncological outcomes appear inferior to rates reported for radiotherapy and surgery.

2 abstracts were summarized from the EAU’s meeting: The HIFU one showed relatievly safe results, but cancer cures that were less than radiation or surgery. This is the first generation device they were using and I expect the results to improve.
I think HIFU will be FDA approved in the US in the next 2-3 years.
The cryosurgical study was for radiation failures and gave the following results and side effects:

The 5-year biochemical recurrence free survival was 73% for low-risk patient, 45% for intermediate-risk men and 11% for high-risk patients. The reported complications included incontinence (13%), erectile dysfunction (86%), LUTS (16%), prolonged perineal pain (4%), urinary retention (2%) and rectovesical fistula (1%).

Prostate cancer options now on google documents.

My prostate cancer counseling sheet.  This is meant to give an idea of
the major forms of prostate cancer therapy and are the main one I focus on at a
consultation for newly diagnosed prostate cancer.  This should only be used
under the supervision of a urologist.
A printable form can be
found online

This was my first venture into google documents and my original experience was extremely positive. My counselling sheet changes periodically based on new treatments or side effects that I want to add. This will be extremely easy to edit without the need for an editor on the computer and can be done anywhere. I will likely place most of my instruction sheets on google documents. It also makes an easy to print out document for patients and has an internal PDF creator built into the online google editor.



Amount of cancer

Size of Prostate (urinary


Bone Scan

CT Scan:

Overview: Reviewed options of
watchful waiting, radiation (brachytherapy, external beam, combination
brachytherapy and external beam), cryotherapy, hormonal therapy and

Watchful waiting.
Usually inadvisable in an otherwise healthy man with a greater than 10
year life expectancy. Prostate cancer that is found early and has a low
Gleason (2-6) may grow slowly and may be monitored rather than treated.

Advantages- No
side effects from therapy.

Cancer eventually may spread and be incurable.

Hormonal therapy.
Prostate cells need testosterone to maintain themselves. Removing a man’s
testosterone may slow down the growth of prostate cancer cells. Usually
inappropriate for long term therapy of localized disease. There is
evidence that the cancer can spread even during long term hormonal
therapy. Hormonal therapy is not curative. Hormonal therapy may be
given prior to radiation.

Hot flashes, osteoporosis, etc.

Radiation: High energy
x-rays are used to kill cancer cells.


Procedure: Performed as
outpatient, under anesthesia. Places radioactive seeds into the prostate
to burnout the cancer from within.

Concerns: Seeds may migrate
during placement leading to over or under treatment of certain areas of
the prostate (and cancer). Therefore, as a sole modality, may be less
effective than external beam or combination radiation therapy.

Side effects: Radiation
cystitis and proctitis (probably will be worse than other forms of
radiation); erectile dysfunction (may be less so than external beam or
combination radiation therapy).

Short duration of therapy. Few side effects up front if the prostate is

Least effective treatment,. Side effects can occur even years after
therapy and may be underappreciated by some radiation oncologists.
Bladder outlet obstruction can occur and be difficult to treat,
especially if the prostate is enlarges.


External Beam:

Procedure: Cast is made of
the body. Radiation is applied to the prostate through many ports,
5d/week for 7-8 weeks. Each session lasts about 20 minutes.

Side effects: Radiation
cystitis, proctitis, and erectile dysfunction.

Cure rates similar to surgery at 10-15 years with hormones added

Daily therapy for 2 months causes a systemic effect. Side effects can
happen later. Radiation effect in long term is unknown- new study shows
a 70% higher rate of rectal cancer after XRT.

Combination External
Beam and Brachytherapy

Combination of above, but
external beam will only last about 5 weeks. Same Side effect profile and
cure rate as external beam alone.


Procedure involves removal of
the entire prostate and seminal vesicles. The goal of this procedure is
to completely remove the cancer while it is contained within the
prostate. Surgery is typically about 3 hours long, and is considered
major surgery. Average blood loss is 2 units, but may be higher.
Patients are usually asked to bank blood for themselves prior to surgery
(“autologous blood”). Average hospital stay is about 3 days. A catheter
remains in the bladder for about 1-2 weeks. Back to work is usually no
sooner than 1 month after surgery.

Small risks of injury to
rectum or ureters, blood vessels, nerves.

Side effects: Incontinence,
usually lasting a few months. Erectile dysfunction.

Advantages: We
can more accurately predict your prognosis. Best long term cure rates.
Least amount of bladder outlet obstruction.

Major surgery with blood loss and recovery.

Robotic Prostatectomy:

The Robotic Radical
Prostatectomy represents a quantum leap forward in prostate cancer
surgery. The da Vinci Surgical System enables urologic surgeons to
perform a radical prostatectomy with similar, or improved technique when
compared to the standard open
procedure, while maintaining all the advantages of minimally invasive

The robot controls tiny
jointed instruments, which can move at the tip like the human hand.
Unlike conventional laparoscopy and its two dimensional image, the da
Vinci camera has two lenses that combine to provide the surgeon a true
3-D image with 10x magnification. Also, any position or movement of the
surgeon’s hands is enhanced with scaling and tremor reduction and is
mirrored in real time.

Advantages of the
minimally invasive procedure may include reduced pain, scarring, risk of
infection, and less operative blood loss. Additionally, these
benefits have translated into shorter hospital stays, faster
recovery times
, and a quicker return to employment and recreational

The robotic radical
prostatectomy can be performed with minimal blood loss and patients are
no longer advised to donate blood for their operation. Patients
typically go home after one night and can return to work within one to
two weeks. The urinary catheter remains in place for approximately six
days and continence is achieved more quickly and completely than with
the other surgical techniques. Erectile function is regained more
quickly and with greater frequency.

Best therapy available with least amount of side effects overall in
experienced hands.

Blood loss is still possible, as are other side effects of surgery.
Surgery can be longer than open for inexperienced surgeons.

Requires a
general anesthetic.

Learning curve
is longer than open surgery.

Cryosurgery: Involves
the use of liquid nitrogen to freeze and destroy cancer cells. Its main
use currently is for the control of local disease if primary therapy is
unsuccessful. Long term results using current technology are still not


Similar to cryosurgery except
we are heating up the prostate with a focused ultrasound probe instead of
icing the prostate.

Probably least amount of side effects overall.

Disadvantages: It
is currently experimental in the US and available in Canada and Europe.

The worst cure
rates at the current time.

HIFU for the treatment of prostate cancer

UroToday – Control of Prostate Cancer by Transrectal HIFU in 227 Patients
HIFU, or high intensity focused ultrasound, works by creating ultrasound waves that are concentrated on the prostate to destroy the tumor cells.
I did research on HIFU for the destruction of kidney tissue when I was a resident at Indiana University. Our institution was doing a clinical research project on using HIFU to treat localized prostate cancer in newly diagnosed men.
This study from France has a much larger series then what we had, and shows some interesting results.
I concentrate on the 14% of patients that still had cancer on biopsy. These biopsies were done after 3 months and is only a small sampling of total prostate tissue, but still shows a high number of cancers.
They also lumped in hormone treatment which can lower PSA values, but cause many side effects and are not curative.
An incontinent rate of 9% is still high as well.
I will await further HIFU studies, but have not seen anything that yet that is an improvement over available therapies.
HIFU is still not FDA approved in our country, but there are centers in Europe and Canada that offer it.