Who can have HIFU?
HIFU is one of a range of treatments for cancer that has not spread outside the prostate gland (localised prostate cancer). HIFU is a relatively new treatment and we do not know very much about how effective it is at treating prostate cancer in the long-term or how it may affect your everyday life. Because of this, HIFU is not widely available as a first treatment. You may be able to have HIFU as part of a clinical trial. Treatment can also be obtained through private healthcare. HIFU may be suitable for you if you have a small prostate gland (less than 40mls), a Gleason score of 7 or lower, and a Prostate Specific Antigen (PSA) of less than 15ng/ ml. It may be more suitable for older men because it is less invasive than surgery (radical prostatectomy). Because HIFU is not suitable for treating large prostate glands you may be given hormone therapy to shrink the gland before starting treatment. Your surgeon may also suggest a transurethral resection of the prostate operation (TURP) to remove excess tissue from the prostate.
How does HIFU treat prostate cancer?
HIFU heats and destroys cancer cells in the prostate. Pulses of ultrasound waves travel through the wall of the back passage (rectum) into the prostate gland and are focused onto a small area. This ultrasound energy causes the prostate cells to heat up. This heat destroys normal prostate cells and cancer cells. The surgeon is able to focus the treatment on the prostate gland and avoid damaging other nearby organs.
What are the advantages and disadvantages?
• HIFU treatment is not as invasive as radical prostatectomy, brachytherapy or cryotherapy.
• It requires a short hospital stay of less than 24 hours.
• The treatment can be repeated if necessary.
• As far as we know, HIFU may be as effective at controlling prostate cancer as some other treatments. However, it is a relatively new treatment and the technology is still developing. Because of this we do not know how effective it is in the long-term (beyond five years).
• If HIFU is your first treatment for prostate cancer, radiotherapy and radical prostatectomy are still possible if HIFU is not successful.
• Trials are currently looking at using HIFU to treat only the areas in the prostate where cancer is present. This is called focal therapy and early information shows it can reduce side effects, although information is not yet available on the medium to long term outcome of this type of treatment.
• You will need a catheter to help you pass urine for between four days and two weeks after the treatment. This is a thin tube that is passed into your bladder, either through the penis or through the wall of your abdomen. If you have HIFU after you have already had radiotherapy, you may need a catheter for a longer amount of time.
• Side effects include a burning feeling when passing urine, needing to urinate more frequently and leaking urine when you cough, sneeze or exercise.
• You may have problems getting an erection after the treatment and may not be able to father children.
• Side effects are more common if you are having repeat treatments with HIFU or if you have already had other treatments for your prostate cancer.
What does treatment involve?
Before the treatment
On the morning of your treatment you will be given some medication, an enema, to help you empty your bowels. An enema is a liquid medication which is given directly into your back passage (rectum). You will be asked not to eat or drink for around six hours before the HIFU treatment. You may also be shown how to use a temporary catheter to empty your bladder before treatment. This is because you may have problems trying to pass urine after treatment once your main catheter is removed. This is called intermittent self catheterisation. If you are having a TURP operation to remove excess prostate tissue, your surgeon will do this before starting the HIFU treatment. This may be carried out immediately before or a few weeks before HIFU treatment. Ask your surgeon when you will have your TURP operation.
You may be given a general anaesthetic so that you are unconscious during the treatment or you may have an injection into your spine (an epidural) so that you are awake but unable to feel anything in your lower body. It is important that you lie still during the operation, so you may be sedated (made drowsy) if you have an epidural. Your surgeon will insert a probe into your back passage (rectum). This probe gives out a series of high intensity ultrasound beams, which are focused on an area of the prostate gland. The probe is surrounded by a cooling balloon, to protect your back passage from the high temperatures. It takes between two to three hours to treat the whole prostate gland. Some surgeons use HIFU to only treat the areas of the prostate gland where cancer is present. This is called focal therapy. This is currently only available as part of a clinical trial. The trial aims to find out whether treating part of the prostate gland is as effective as treating the whole gland and whether it causes fewer side effects. If you have focal therapy (see the section on advantages of HIFU for an explanation of this) then treatment lasts between 30 minutes to 1 ½ hours.
Going home after treatment
You will be able to go home once you have recovered from the anaesthetic, you are feeling comfortable and you have been shown how to look after your catheter. This will usually be on the day of your HIFU treatment. Your doctor will check that you are fit to go home and you have someone to look after you. Your specialist team will give you antibiotics and painkillers to take at home. You will also have an appointment to return to the hospital to have your catheter removed. You may notice blood in your urine while your catheter is in place. You may also notice some small pieces of tissue in your urine for up to two months after your HIFU treatment. Some bleeding and pieces of tissue in the urine are quite normal, however contact your doctor if you are worried or develop any new symptoms such as pain or a temperature.
What happens afterwards?
After your HIFU treatment you will have regular appointments with your specialist team to check your PSA level and monitor any side effects, such as problems passing urine and erection problems. Your PSA level should reach its lowest level three to four months after your treatment. Your PSA should fall to less than 0.5ng/ml. If your PSA does not fall to this level or if it starts to rise again, you may need to have a biopsy to see if cancer cells are present in the prostate gland. If prostate cancer cells are present, your specialist team may offer you further treatment. This is sometimes called ‘salvage’ treatment. Treatment options may include: • Repeat HIFU therapy • Radical prostatectomy • External beam radiotherapy • Cryotherapy • Hormone therapy
What are the side effects?
The most common side effects are described here but there is no way of knowing which of these you will get, or how bad they will be. Ask your specialist team for more information on the risk of side effects. They should be willing to show you the results of the treatments which they have carried out and put you in touch with other men who have had the treatment.
HIFU can cause problems passing urine. However, you are less likely to get the side effects described below if you have had a TURP operation before having HIFU. Between 10 per cent and 50 per cent of men treated with HIFU will get a urine infection after treatment. If this happens to you, your doctor will prescribe you a course of antibiotics to clear the infection. Studies show different rates of urinary incontinence after HIFU.
Some men may leak small amounts of urine when they cough, sneeze or exercise. This is called stress incontinence. Only a small number of these men may need incontinence pads to help manage this. The risk of getting this side effect after HIFU is lower than other treatments, such as radical prostatectomy, brachytherapy and radiotherapy.
HIFU treatment may cause your prostate gland to swell temporarily. This may make it difficult for you to pass urine for up to a week or two after treatment. You will have a temporary catheter to drain urine from your bladder. After you have recovered from HIFU treatment, you may notice that your urine flow is slow. This may be caused by a narrowing of the urethra or the neck of the bladder. This affects about one third (30 per cent) of men who have had HIFU treatment. Your doctor may treat this with a minor procedure to stretch the narrowed area. The risk of this is lowered if you have a suprapubic catheter. A suprapubic catheter goes directly into the bladder through the skin of your abdomen.
You may find that you need to pass urine more often and with less warning than before treatment. You may also get a burning feeling when you do pass urine. You can help to improve these symptoms by avoiding drinks that contain caffeine, such as tea, coffee and cola. For information on how urinary problems can be controlled and treated, please read our Tool Kit fact sheet Urinary continence and prostate cancer.
Studies show different figures for the number of men who find it difficult to get an erection after HIFU treatment. The number of men affected may be as low as one in five (20 per cent) or as high as four in five (77 per cent). However, these figures are no worse than for radical prostatectomy or radiotherapy. You may also notice that you produce no semen or less than usual. If you have had a TURP operation before HIFU, you may find that when you orgasm, the semen travels backwards into the bladder rather than out through the penis. This is called retrograde ejaculation. It is not harmful but it may change your enjoyment of sex.
Some men get a burning sensation or some bleeding from the back passage after HIFU treatment. Very rarely HIFU may cause a hole (fistula) between the urethra and the back passage. This affects less than one in 100 men (one per cent), however it is more common in men who have previously had radiotherapy or brachytherapy.