Consultant Urologist, The Princess Grace Hospital and Institute of Urology,
University College, London
Balancing the toxicity of treatments for prostate cancer against the benefits is a key decision-making issue for patients with their clinicians as the consequences of each treatment does vary.
Following assessment of the presence of the disease using PSA, ultra sound, MRI or a combination of these, a range of options are available:
- Active surveillance/watchful waiting - monitoring any progress of the disease, without treatment
- Radical prostatectomy, increasingly using minimally invasive laparoscopic techniques and now robotic surgery
- Radiotherapy
- And now, HIFU (High Frequency Ultrasound)
HIFU is non-invasive and leaves the prostate gland, surrounding tissue and nerves intact and in situ. A probe is inserted per rectum, delivering the high frequency ultrasound to the prostate gland, guided by the surgeon working on a computer screen.
The key benefits of HIFU are:
- Non-invasive
- Out-patient treatment
- Avoidance of surgical site
- Avoidance of ionising radiation
- Repeatable
- Versatility
- Makes 'surgical sense'
Determinants of outcome from HIFU are:
- Energy exposure - visually directed HIFU
- nEnergy application
- Power doppler
- Neurovascular blood flow preservation
- MRI characterisation of results
- Competency based training programme
- Web based registry
- Quality standard for primary therapy
- SA <0.2ug/L in > 90% of patients
Tolerability/acceptability of HIFU:
- Appears to conform to patients' 'ideal therapy'
- 'Painless'
- 'Non invasiveness'
- 'Lack of disruption'
- 'Repeatability'
- 'Conceptually appealing'
- 'Futuristic'
Can be used in the 'difficult' cases:
- Anticoagulated patients
- Ulcerative colitis
- Diverticulosis
- Previous TURP
- Previous pelvic surgery
- Previous pelvic radiation
- Narrow pubic arch.
HIFU has the potential to improve the harm/benefit ratio associated with standard therapies and has the necessary attributes to explore other indications - focal therapy, high risk disease, T3 disease. It is a rapidly developing technology and is likely to have an important role in the management of prostate cancer in the foreseeable future.
