HIFU – Procedure for Prostate Cancer
When a man and his family are confronted with a diagnosis of cancer, fear and confusion are two very common emotions that are experienced. Finding a way to balance treatment that maximizes years-of-life with those geared toward quality-of-life can be difficult and we are here to help guide your decision making with state of the art treatment options for prostate cancer.
Your Cancer…Your Choice
We are available for a free second opinion with one of our treating Urologists to discuss your case on the phone.
HIFU technology ablates prostate tissue by focusing high-intensity ultrasound waves on the affected area, causing localized heating that destroys the cells in the gland without damaging the healthy surrounding tissue. Focused ultrasound works in the same way as rays of sunlight that pass through a magnifying glass and are concentrated at a single point, causing a significant temperature rise around the focal point. Thermal ablation is a non-invasive (incisionless and radiation-free) procedure that has been used in humans since 1993. With more than 45,000 treatments performed using a HIFU medical device, the HIFU treatment is recognized by orders of urology specialists in several countries across the world.
What is HiFU and how does HiFU treat Prostate cancer?
Robotic HIFU prostate tissue ablation is a non-invasive procedure, which means that no incision is made, therefore leaving no scar. The impact on neighboring organs such as the urinary sphincter (incontinence) and erectile nerves is limited (1). The HIFU procedure probe is inserted into the rectum, enabling very easy access to the prostate, which is located immediately behind the rectum wall.
(1) Focal therapy with HIFU for localized prostate cancer: a prospective multicentric study. Rischmann P. et al.  EAU 2014
Repeatable radiation-free procedure
Repeatable radiation-free procedure
Unlike radiotherapy radiation, ultrasound waves are quite harmless. They are used in a range of applications including ultrasound imaging during pregnancy. With HIFU technology, the same harmless waves are produced at a higher intensity and focused to create a therapeutic effect for prostate tissue ablation (2).
(2) Morbidity associated with repeated transrectal high-intensity focused ultrasound treatment of localized prostate cancer, Blana A. et al. World J Urol (2006) 24:585-590 DOI 10.1007/s00345-006-0107-x
Custom treatment: radical or focal approach
With HIFU medical devices, the urologist is able to provide a personalized procedure, taking into account the anatomy of the prostate, the patient’s preferences and any other procedures already received. The urologist may decide to treat only the target area within the prostate (in a “focal” strategy) rather than ablating the entire prostate (in a “radical” strategy), in order to maintain the maximum quality of life by limiting the impact on the surrounding tissue.
Robotic procedure for maximum precision and safety
The urologist plans the HIFU procedure and the machine then precisely executes the instructions, with movements that are accurate to the millimeter, which is not possible when working by hand. HIFU medical devices are equipped with many automatic safety features and procedure parameters can be monitored in real time for maximum safety and effectiveness.
What is the equipment used in your practice?
We use BOTH the Ablatherm™ AND FOCAL ONE (TM) machineS manufactured by EDAP Technologies based here in Austin, TX. We have MRI fusion capabilities and the option of performing either Focal or Whole Gland prostate HiFU that is robotically controlled and guided by real-time images of the prostate by ultrasound.
Who is our HiFU Team?
Dr. Sandeep Mistry
Dr. Sandeep Mistry and the entire provider team at Urology Specialists have decades of experience managing prostate cancer. Dr. Mistry’s award winning research with the Howard Hughes Medical Institute was focused on understanding metastatic prostate cancer at a molecular level and he has been performing robotic prostate removal since 2007. He is a leader and teacher when it comes to prostate cancer surgery and has become one of the nation’s leading providers of minimally invasive prostate cancer treatment with HiFU. He is currently a recognized proctor for HiFU and trains physicians from throughout the country to spread the availability of treatment.
Dr. Stacy Ong
Dr. Stacy Ong was staff physician at University Medical Center at Brackenridge for nearly 10 years where she was responsible for the care of the very most vulnerable in our community often with the worst extent of disease.
Dr. Christopher Yang
Dr. Christopher Yang is a board-certified Urologist who trained at the University of Illinois at Chicago. He has experience with robotic, endoscopic and open prostate surgery and had dedicated his career to restoring erectile function with advanced surgery and management.
Dr. Lucas Jacomides
Dr. Lucas Jacomides was the head of Urology for the Round Rock Campus of Baylor Scott and White and it’s Chief od Staff. He deeply understands the need to look beyond the mainstream to look for prostate cancer solutions that will help men achieve the goal of living their best life.
Why has my doctor not told me about the procedure?
Simply put, most U.S. physicians have not been trained to perform HiFU and are unlikely to have access to a machine. Also, because Medicare only partially pays and commercial insurances largely do not pay for the procedure, many Urologists find it difficult to explain the economics of this treatment even though erectile dysfunction, incontinence and surveillance all have costs, both economic and physical.
Finally, many Urologists and institutions have invested millions of dollars into Radiation machines that are a direct alternative to HiFU treatment. They may be hesitant to advise a treatment that would devalue those investments. With prostate cancer, as much as any other similar diagnosis, you will most likely be offered the treatments that your doctor feels comfortable providing and getting additional opinions is critical.
Prostate Cancer is not a simple or single disease. Although over 300,000 men are diagnosed with the disease, only about 10% will dies from the disease and there is a real concern that men are being overtreated. So, if your doctor thinks that you would not fare well with complications or that you are too old or sick to benefit from treatment you may not be steered towards treating your prostate cancer.
How well will HiFU work?
Data in regards to HiFU has been collected over the last 20 years. To understand your specific cancer we encourage you to visit the following site to get your 10 year mortality and results after radical prostatectomy.
We generally counsel patients that HiFU is about 90% as effective as radical surgery. Balancing your desire for cancer cure versus concerns about functional side effects will greatly impact your decision regarding prostate cancer treatment.
The following articles will give you all the efficacy information and side-effect information you would need for a decision.
Read Peer Reviewed Articles
- “Focal Treatment for Unilateral Prostate Cancer Using High-Intensity Focal Ultrasound: A Comprehensive Study of Pooled Data” – Albisinni et al. – Journal of Endourology 2018: https://pubmed.ncbi.nlm.nih.gov/29790383/
- “Comparing High-Intensity Focal Ultrasound Hemiablation to Robotic Radical Prostatectomy in the Management of Unilateral Prostate Cancer: A Matched-Pair Analysis” – Albisinni et al. – Journal of Endourology 2017: https://pubmed.ncbi.nlm.nih.gov/27799004/
- “Focal High Intensity Focused Ultrasound of Unilateral Localized Prostate cancer: A Prospective Multicentric Hemiablation Study of 111 Patients” – Rischmann et al. – European Urology 2017 – https://pubmed.ncbi.nlm.nih.gov/27720531/
- “Focal High-intensity Focused Ultrasound Targeted Hemiablation for Unilateral Prostate Cancer: A Prospective Evaluation of Oncologic and Functional Outcomes” – Cordeiro Feijoo et al. – European Urology 2016 – https://pubmed.ncbi.nlm.nih.gov/26164416/
- “Hemi salvage high-intensity focused ultrasound (HIFU) in unilateral radio-recurrent prostate cancer: a prospective two-centre study” – Baco et al. – British Journal of Urology International 2013 – https://pubmed.ncbi.nlm.nih.gov/24930692/
- “Whole-gland Ablation of Localized Prostate Cancer with High-intensity Focused Ultrasound: Oncologic Outcomes and Morbidity in 1002 Patients” – Crouzet et al. – European Urology 2014 – https://pubmed.ncbi.nlm.nih.gov/23669165/
- “Evolution and outcomes of 3 MHz High intensity focused ultrasound therapy for localized prostate cancer over 15 years” – Thueroff et al. – Journal of Urology 2013 – https://pubmed.ncbi.nlm.nih.gov/23415962/
- “Fourteen-year oncological and functional outcomes of high-intensity focused ultrasound in localized prostate cancer” – Ganzer et al. – British Journal of Urology International 2013 – https://pubmed.ncbi.nlm.nih.gov/23356910/
- “Salvage high-intensity focused ultrasound (HIFU) for locally recurrent prostate cancer after failed radiation therapy: Multi-institutional analysis of 418 patients” – Crouzet et al. – British Journal of Urology International 2017 – https://pubmed.ncbi.nlm.nih.gov/28063191/
- “Locally recurrent prostate cancer after initial radiation therapy: Early salvage high-intensity focused ultrasound improves oncologic outcomes” – Crouzet et al. – Radiotherapy and Oncology 2012 – https://pubmed.ncbi.nlm.nih.gov/23068708/
- “A prospective study of salvage high-intensity focused ultrasound for locally radiorecurrent prostate cancer: Early results” – Berge et al. – Scand J Urol Nephrol. 2010 – https://pubmed.ncbi.nlm.nih.gov/20350272/
- “High-Intensity Focused Ultrasound for the Treatment of Prostate Cancer: A Review” – Chaussy et al. – Journal of Endourology 2017 – https://pubmed.ncbi.nlm.nih.gov/28355119/
- “HIFU as salvage first-line treatment for palpable, TRUS-evidenced, biopsy-proven locally recurrent prostate cancer after radical prostatectomy: A pilot study” – Asimakopoulos et al. – Urologic Oncology 2010 – https://pubmed.ncbi.nlm.nih.gov/21292508/
- “Salvage Radiotherapy After High-Intensity Focussed Ultrasound for Recurrent Localised Prostate Cancer” – Riviere et al. – European Urology 2010 – https://pubmed.ncbi.nlm.nih.gov/20598436/
HiFU vs. Active Surveillance
Why would I choose HiFU over Active Surveillance (Watchful Waiting), Robotic Prostate Cancer Removal,
or Radiation (either external bean, Cyberknife, or radiation seeds)?
Watchful Waiting or Active Surveillance is an excellent choice for patients with small volume prostate cancer or those with poor health or those wanting to avoid all sexual and urinary side effects of treatment. Unfortunately, this treatment strategy involves, repeat biopsies, regular lab draws and doctor visits and the anxiety shared between you and your loved ones.
Carefully weigh and balance the risks.
We will generally advise our patients who have Prostate Cancer localized to the prostate who are interested in treatment to carefully weigh the risks of each choice and balance the risks with the expected cure rate. Men who have aggressive cancer and a long life expectancy will generally be advised to have a radical robotic prostate removal. However, many men, even with advanced cancer, would rather proceed with HiFU to preserve sexual and urinary function even though additional treatment may be required in the future.
Many of our patients are advised against radiation for several reasons:
- Most patients deemed appropriate for radiation are excellent HiFU candidates.
- The side effects of radiation, including developing other cancers, may not be seen for many years
- HiFU can be done in several hours in one visit
- HiFU can be used to treat only the part of the prostate affected by cancer
- Surgical removal of the prostate remains a possibility after HiFU
- Radiation can be kept as a treatment for salvage if the cancer return
The HIFU prostate tissue ablation procedure is designed to preserve quality of life
Prostate care treatments can alter patients’ quality of life in terms of pelvic comfort, urinary continence, sexuality and values. Today’s treatment options are not only about curing or prolonging life: they also aim at reducing the comorbidities of the disease and the side effects of treatments, to fight against possible sequelae. HIFU treatment is also a perfect alternative to active monitoring and radical treatment by surgery or radiotherapy. Being effective in a minimally invasive manner, it preserves the quality of life of patients by removing the psychological stress that active surveillance can represent for the patient.
Frequently Asked Questions
Where is the procedure performed?
Currently we perform the procedure at either Westlake Medical Center (5656 Bee Caves Rd, West Lake Hills, TX 78746) or Arise Medical Center summary.ab-accordion-title here in Austin. These hospitals have provided the best price for our patients and there are several very nice hotels for the overnight stay for out-of-town patients the night before the procedure. We have a special rate for patients at the Hotel Granduca (320 S Capital of Texas Hwy, West Lake Hills, TX 78746).
What can I expect during the procedure?
Our procedure is performed in a hospital because a general anesthetic and paralysis is necessary to maintain the robotically controlled preplanning that is required. The procedure takes between 1 and 3 hours. You will need to prepare for the procedure with enemas and 8 hours of fasting.
You will get anesthesia and shouldn’t feel any pain during the procedure. The doctor will thread a small tube called a catheter through the head of your penis and into your bladder to catch urine during the procedure.
Your doctor will put an ultrasound probe into your rectum. It’s a small instrument like the ones used for prostate biopsies. The probe may have one or two crystals inside. Sound waves from a crystal bounce back to a computer to make a picture of the prostate gland. Any MRI images of your cancer will then be used to create a treatment program that is saved with your real-time prostate images. The nerves that control erections and the sphincter that controls continence as well as the delicate rectal wall are all imaged and protected from treatment. The ultrasound energy is then directed precisely to the prostate and temperature and treatment depth is monitored. Care is taken to adjust the treatment as the prostate can change anatomy due to the heat.
After the procedure is done and the anesthesia wears off, you can usually go home. Depending on several factors you will keep the catheter for one or two weeks after the procedure. If you are a Medicare patient, we will arrange home health for catheter management and removal even if you live outside of Austin. Otherwise we will remove your catheter or arrange a local physician to do so.
What does HiFU cost and what will my insurance cover?
The lack of insurance coverage is perhaps the only reason that HiFU has not become a standard for Prostate Cancer management in the United States. Currently, the process of establishing ‘codes’ and ‘prices’ for insurance companies are underway. Medicare and other government programs including Medicare Advantage plans have covered a portion of the procedure for several years.
- For Medicare, Medicare Advantage, Tricare, Medicaid and some VA patients, the cost is $6,000 to include the HiFU treatment, anesthesia, machine rental, equipment and hospital fees.
- For Commercial Insured or non-insured patients the cost is $13,500 to include the HiFU treatment, anesthesia, machine rental, equipment and hospital fees. For these patients we will also cover the cost of the Erectile Rehabilitation program that is outlined below.
What tests are usually required prior to the procedure?
Generally, we would like to see:
- Your pre-biopsy PSA
- Your actual biopsy results
- 3T MRI of the prostate
- Staging examination including a bone scan and CT of the abdomen
We will order these for you in your local area if your do not have them.
Why choose our practice for your HiFU Treatment?
We are a comprehensive prostate cancer and men’s wellness clinic with decades of experience balancing life-saving surgery with lifestyle maximization. You want a practice that has more than one tool for prostate cancer and you want a Urologist in charge of your prostate cancer treatment program, potency and continence. We actively treat hundreds of prostate cancer patients with surgery, radiation, active surveillance and HiFU every year. We have a strong holistic approach that includes nutrition, preventative supplements and aggressive maintenance of your most intimate functions. It is that commitment to your overall health that should compel you to trust us to advise you best on your prostate cancer.
What if I do not live in Austin?
Approximately 70% of our patients travel for treatment. We will try to make the experience as easy as possible. Most of the pre-consultation and preparation is done on the phone. You will meet us the day before the procedure and are free to go home the day of the procedure. We have special rates at several local hotels and will try to help make travel arrangements if needed.
Why might I be asked to have a procedure before the HiFU?
The HiFU technology is somewhat limited on the size of prostate that can be treated. For patients that will undergo FOCAL therapy of only one or more locations of the prostate, the size of the prostate will generally not interfere with the procedure. For those that have extensive cancer and will require WHOLE GLAND treatment may need a pre-HIFU procedure to reduce the size of the prostate. This is generally an overnight or outpatient surgery and can be performed by your local urologist if traveling to Austin on 2 separate visits is not something you would be willing to do. We would encourage you not to let this aspect of the process discourage you. The reasons you would choose HiFU as a means of maintaining lifestyle remains intact. The name of the procedure is Transurethral Resection of the Prostate (TURP) and is a vastly different procedure in terms of time, safety and recovery than the procedure of the same name your father may have had. We can discuss it further when you have your consultation.
How am I followed after the HiFU?
We will generally get a PSA level at 3, 6, 9, and 12 months and make a plan afterwards. We will monitor erectile and urinary function and make any necessary plans to address issues. All follow-up, diagnostic testing and labs are covered under all insurance plans.
What if HiFU does not work?
With HiFU, you still have the option of surgical removal or Radiation therapy if the cancer returns. You will also have the opportunity to repeat HiFU if the cancer returns in a different area of the prostate.
Explain your post HiFU Erectile Rehabilitation Program (ERP)?
The energy and temperature from HiFU may affect the Neurovascular Bundles of the prostate and affect erections. In addition, virtually all treatments for prostate cancer result in patients feeling that their erections and flaccid penis are shorter. To help encourage blood flow to the penis and maintain length we will begin a program of high quality L-arginine and curcumin supplements, daily tadalafil and the regular daily use of a Vacuum Erection Device. All instructions will be given at time of consultation and will begin shortly before HiFU.This is also the program we use after a radical robotic prostate removal surgery.
Will I have incontinence after HiFU?
Generally, you will not have STRESS incontinence after the procedure as the urethral sphincter will be visualized and protected from damage. Some patients may have temporary URGE incontinence that can be managed with medication as the prostate heals.
Can I have HifU after radical surgery or radiation if
the cancer returns?
HiFU is not possible for PSA recurrence after Radical Prostate Removal Surgery.
However, HiFU can be used for PSA recurrence after radiation therapy after it is confirmed that the prostate cancer is confined to the prostate.
What side effects are expected with HiFU, especially related to impotence and incontinence?
Therapeutic advances and improvements in prostate condition management have recently placed quality of life at the heart of patients’ decision. Quality of life is akin to a person’s judgment on his life and his psychic equilibrium. It is therefore a very subjective concept that makes its assessment difficult. Therapeutic advances, the willingness to involve patients in decisions about themselves, or rationalization of healthcare expenditure may explain why health-related measures of quality of life have been developed in recent years alongside morbidity and mortality indices.
HiFU allows for direct visualization and avoidance of the Neurovascular Bundles (NVB) that control erections and the sphincter that controls continence. When appropriate, these structures can be avoided to maximize your quality of life.
Complications of HiFU can include the development of a Urethral Stricture, narrowing of the urethra that slows or stops urine flow. Another potential complication is a fistula (or unnatural connection) between the urethra and the rectum. This is more common if HiFU is done after radiation. There are precautions taken to avoid these issues and the Ablatherm HiFU device is specifically designed to avoid rectal wall damage.
What is the role of HiFU in oligometastatic disease?
In the past, any evidence of prostate cancer outside of the prostate was considered too advanced for some forms of local therapy. Today, many oncologists believe that evidence of disease in only one or two locations outside of the prostate (oligometastasis) may be treated with therapy directed at the prostate and focal therapy to the areas of spread. HiFU can play a role in these patient with oligometastatic disease in combnation with focused radiation therapy for the areas of spread.
How do I learn more about treatment for myself or a loved one?
Please call us or email us at firstname.lastname@example.org and we will set up a FREE telemedicine consultation with one of our UROLOGISTS to discuss YOUR specific case. If you can get your materials together we can discuss your individual case or we can simply talk about the treatment in general terms.
It is up to YOU. Your Cancer…Your Choice.
Preparing for your procedur
The Ablatherm is a state of the art device. It uses a high performance, high intensity focused ultrasound technology that allows the ablation of prostate tissue with minimal morbidity. The unique technology makes it possible to target and destroy the parts of the prostate, sparing the rest of the organ and therefore minimizing side effects. Instead of using radiation, high intensity sound waves are used to heat up and burn the targeted tissues, choking off the blood supply and causing cell death. This procedure is in no way a therapy roadblock, as it is repeatable and can be followed, like for a prostatectomy, by external radiotherapy. It preserves the erectile nerves and urinary sphincter thanks to the precise targeting of lesions.
BEFORE YOUR PROCEDURE
- Continue to take other prescribed medications, UNLESS it is on the enclosed list of drugs to avoid. This is important, especially if you are diabetic or being treated for high blood pressure.
- Your physician has prescribed an antibiotic or given you a sample, to be taken for seven (7) consecutive days. Begin taking pills day of the procedure that evening.
- Ten (10) days before your procedure: stop taking any Plavix after talking to the prescribing doctor.
- Seven (7) days before your procedure: stop taking Coumadin, Pradaxa, Eliquis, Xarelto, aspirin, Advil, Motrin, Ibuprofen, or Aleve.
- Take the antibiotic on the day of the procedure and for six (6) days afterward.
- You will need to purchase 2 Fleet’s enemas from the drug store. On the day of the test, administer the Fleet’s enemas Two (2) hours prior to your scheduled appointment.
- You will need someone to drive you to and from the procedure.
- You will need to be on a clear liquid diet the day prior to the procedure. This includes: water, broth, jello, fruit juices without pulp, tea, coffee or ensure clear.
- Nothing by mouth after midnight before the procedure. You may have a small sip of water with any medications that morning.
After the procedure
At the end of the procedure, a temporary urinary catheter will be placed in order to limit the risk of urinary retention due to the temporary swelling. You will wear this catheter for 1-2 weeks depending on specifics of your individual case. We recommend no strenuous activity while the catheter is in place.
- You will continue your antibiotic for 6 days post procedure.
- You will need to take a stool softener and stay hydrated to limit constipation.
- We may prescribe a bladder antispasmodic such as Mybetric or Vesicare
- We may also recommend penile rehabilitation, which includes the use of oral medication such as Cialis, or a vacuum erection device.
- You may take Tylenol or ibuprofen as directed for pain if necessary.