High intensity focused ultrasound (HIFU)

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What is HIFU?

High-intensity focused ultrasound (HIFU) uses high-frequency ultrasound energy to heat and destroy cancer cells in the prostate. A beam of ultrasound energy travels into the prostate from a probe put into the back passage (rectum).

There are two types of HIFU:

focal HIFU, which treats areas of cancer in the prostate and a small area around them
whole-prostate HIFU, which treats the whole prostate.

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Who can have HIFU?

HIFU might be suitable for you if your cancer hasn’t spread outside your prostate (localised prostate cancer) and has a low or medium risk of spreading.

HIFU is sometimes an option if your prostate cancer has started to break out of your prostate, has spread to the area just outside the prostate (locally advanced prostate cancer) or has a high risk of spreading. But your cancer may be more likely to come back after treatment than in men with localised cancer.

HIFU isn't an option if your cancer has spread outside your prostate to other parts of your body (advanced prostate cancer).

HIFU can also be used to treat cancer that has come back after previous HIFU or radiotherapy (recurrent prostate cancer). This is called salvage HIFU.

HIFU may not be suitable if you have a large prostate. Focal HIFU may still be an option if the areas of cancer are close enough to the probe for the ultrasound to treat. Your scan and biopsy results will show whether this is the case. Whole-prostate HIFU may still be an option if you have another treatment, such as a transurethral resection of the prostate (TURP), laser treatment or hormone therapy, to shrink the prostate first.

In the UK, HIFU is only available in specialist centres in the UK or as part of a clinical trial. This is because it is newer than some other treatments, so we don’t know how well it works in the long term.

Speak to your doctor about whether HIFU is a suitable option for you and whether it’s available in your area. If it’s a good option for you, your doctor may refer you to a specialist HIFU centre.

What are the advantages and disadvantages of HIFU?

What may be important for one person might not be so important for someone else. If you’re thinking about having HIFU, speak to your doctor or nurse before deciding whether to have it. They can help you choose the right treatment for you. Take time to think about whether you want to have HIFU.

Advantages

HIFU doesn’t involve any cuts to the skin or needles, apart from a needle in your hand to give you a general anaesthetic.
Focal HIFU can treat small areas of cancer while causing little damage to nearby tissue, nerves and muscles.
You only need a short hospital stay – you can usually go home on the same day as your treatment.
Recovery is usually quick and most men return to their normal activities within two weeks.
HIFU is less likely than surgery to cause erection or urinary problems.
You may be able to have HIFU if your cancer has come back after radiotherapy.
You may be able to have HIFU again if your cancer comes back after your first HIFU treatment. This isn’t the case with all treatments.
You may also be able to have other treatments after HIFU if your cancer comes back, such as surgery or radiotherapy.

Disadvantages

In the UK, HIFU is only available in specialist centres or as part of a clinical trial. You may need to travel a long way to your nearest treatment centre.
Compared with other treatments, we don’t know how well it works in the longer term (after 10 years).
As with other treatments, you may get side effects, such as erection and urinary problems.

What does HIFU involve?

Each hospital will do things slightly differently. We’ve included some general information about what might happen before, during and after HIFU. Your doctor or nurse will give you more information about your treatment.

Before your treatment

If you have a large prostate, you might be offered other treatments before you have HIFU.

Hormone therapy is sometimes given for two to three months before HIFU. This can make the prostate smaller, and make the cancer easier to treat.
Transurethral resection of the prostate (TURP) is an operation to remove prostate tissue and improve the flow of urine. This operation is sometimes used before HIFU to reduce the risk of some urinary problems after the treatment.

As with all treatments, these can cause side effects.

If you’re having focal HIFU, you will usually go to a screening appointment first. You’ll have a magnetic resonance imaging (MRI) scan, which produces detailed images of the prostate and shows the location of the cancer. You may also have a prostate biopsy, which shows the location of the cancer and how likely the cancer is to grow and spread outside the prostate. These tests will help your surgeon target the area of the prostate that needs to be treated.

During your treatment

On the morning of your HIFU treatment, you’ll be given an enema to empty your bowels. This makes it easier for the doctor to see clear images of your prostate. An enema is a liquid medicine that is put inside your back passage (rectum). You’ll also be asked not to eat or drink for around six hours before the HIFU treatment.

You will have a general anaesthetic so that you’re asleep during the treatment.

During your treatment, you will need to lie on your back with your legs apart. You may have a catheter put in at the start of the treatment to drain urine (wee) out of your bladder. A catheter is a thin tube that is passed into your bladder, either through the penis or through the wall of your abdomen (stomach area).

Your surgeon will place a probe inside your back passage (rectum). The probe gives out a beam of high-intensity ultrasound energy, which travels through the wall of the back passage into the prostate. The beam treats one small area of the prostate at a time – the size of a grain of rice.

Your surgeon will plan your treatment so the HIFU machine moves the beam around, heating and destroying the cancer cells in the area being treated.

The probe also uses ultrasound to create images of the prostate while your surgeon is treating it. This helps the surgeon target the cancer and avoid healthy tissue like the urethra, which is the tube you urinate (pee) through.

The probe is surrounded by a cooling balloon so that the heat doesn’t damage your back passage.

If you have a large prostate, you may be offered a transurethral resection of the prostate (TURP) or laser treatment. These treatments remove prostate tissue to improve your flow of urine, reducing the risk of some urinary problems afterwards. You may have this straight after your HIFU treatment, under the same anaesthetic.

Read our information on enlarged prostate.

Focal HIFU

You may also hear focal HIFU called focal therapy or partial ablation with HIFU. It treats areas of cancer in the prostate and takes one to two hours. It may be suitable for men who have small cancers that need treating in only one or two areas of their prostate.

Your surgeon will treat the areas of cancer that need treating and a small area around them. Less of the healthy tissue is damaged during focal HIFU compared to whole-prostate HIFU.

Some men who have focal HIFU have only one area of cancer in their prostate.

Other men have more than one area of cancer in their prostate, but some areas are not treated on purpose (see diagram below). The cancer that is not treated is less likely to spread (low-risk cancer) and it may not cause any problems. These men will have regular tests to keep an eye on the cancer that is not treated.

With focal HIFU, there is a small risk that some areas of cancer that do need treating may be missed if they weren’t picked up by the scan and biopsy. If this happens, there are further treatments that you can have.

Whole prostate HIFU

Whole-prostate HIFU treats the whole of the prostate and takes about three hours. It is less common than focal HIFU but may be suitable for men who have prostate cancer that needs treating in more than one area of their prostate.

After your treatment

You should be able to go home on the same day as your treatment. Your doctor or nurse will check that you’ve recovered from the anaesthetic and are fit to go home. You shouldn’t drive for 24 to 48 hours after the anaesthetic. Ask a family member or friend to take you home.

You may have pain in the area between your testicles and back passage, but you’ll be given pain-relieving medicine if you need it.

You will also get antibiotics to prevent any possible infection and may be given a medicine called a laxative to help you empty your bowels.

HIFU usually causes the prostate to swell to begin with, which can make it difficult to urinate. You’ll have a catheter to drain urine from your bladder until the swelling has gone, usually for up to a week after treatment.

Before you go home your doctor or nurse will show you how to look after your catheter. They’ll also give you an appointment to have your catheter removed.

What are the side effects of HIFU?

Like all treatments, HIFU can cause side effects. These will affect each person differently, and you might not get all of them.

The most common side effects are urinary problems and difficulty getting or keeping an erection (erectile dysfunction).

Having HIFU more than once may increase your risk of urinary problems, but it doesn’t appear to increase your risk of other side effects.

Less of the healthy tissue is damaged during focal HIFU than with whole-prostate HIFU, so there’s a lower risk of side effects such as urinary and erection problems.

If you have hormone therapy or a TURP as well as HIFU, these can also cause side effects.

Short-term side effects

The following side effects can develop soon after your treatment and may include:

blood or tissue in your urine
erection problems
urine infections
urinary problems
testicle infections.

Blood or tissue in your urine

You might see some blood in your urine while the catheter is in place. You might also see some small pieces of prostate tissue in your urine for six to eight weeks after HIFU. This is normal. If you are worried or see signs of an infection, speak to your doctor or nurse straight away.

Erection problems

Some men have problems getting or keeping an erection (erectile dysfunction) after HIFU. This is because it can damage the blood vessels and nerves that control erections. For some men this will improve, but for others this will be a longer-term side effect of HIFU. There are treatments that can help with erection problems.

Urine infections

Some men get a urine infection after HIFU. Signs of a possible urine infection include:

a fever (high temperature)
feeling shivery
a burning sensation when you urinate
dark or cloudy urine with a strong smell
needing to urinate more often than usual.

Tell your doctor or nurse if you have any signs of a urine infection. They’ll usually give you antibiotics to treat the infection.

Urinary problems

Some men need to urinate more often than usual after HIFU. This is called urinary frequency and usually gets better over time.

Some men find it hard to empty their bladder properly after their catheter is removed – this is called urine retention. After HIFU, the treated prostate tissue can block the urethra. If your flow of urine is weak or slow after your catheter is taken out, speak to your doctor or nurse.

If you can’t urinate at all, call your doctor or nurse straight away or go to your nearest accident and emergency (A&E) department. They may need to drain your bladder using a catheter.

They might also suggest using a temporary catheter (self-catheterisation). This is where you put a catheter in yourself when you want to urinate and take it out afterwards. Some men find that urinary problems improve over a few weeks, but other men need further treatment to clear the blockage.

Testicle infections

Some men get an infection in the testicles or the tubes that carry sperm from the testicles. Signs of a possible infection include pain, swelling and tenderness in one or both testicles. Tell your doctor or nurse if you have any of these symptoms. They’ll usually give you antibiotics to treat the infection.

Fatigue

Some men feel extreme tiredness (fatigue) after having HIFU. Fatigue can affect your everyday life. It can affect your energy levels, your motivation and your emotions – which can be hard to cope with. As HIFU is quite a new treatment, we don’t yet know how long fatigue may last for.

We have lots of information on fatigue on our website, as well as an interactive online guide with tips to help you manage fatigue. You might also want to try our Specialist Nurse-led fatigue support service, which can help you make lifestyle changes that should improve your fatigue over time.

Longer-term side effects

Most side effects will settle down after HIFU, but some men have longer-term side effects or problems that develop later, including:

sexual problems
urinary problems
a hole between the back passage and the urethra (called a rectal fistula).

The risk of longer-term side effects is lower after focal HIFU than after whole-prostate HIFU.

Sexual problems

Some men get erection problems that improve over time, but other men find that their erection problems don’t improve. There are treatments that can help manage erection problems.

You should still be able to orgasm (climax) after HIFU, but you might release less semen (the fluid that carries sperm), or no semen at all. This means you may not be able to have children naturally after treatment. If you’re planning to have children, you might be able to store your sperm before HIFU to use in fertility treatment. If this is important to you, ask your doctor or nurse about it.

You may find that when you orgasm, the semen travels backwards into the bladder rather than out through the penis. The semen is then passed out of the body when you next urinate. This is called retrograde ejaculation. This is more common if you’ve had a TURP before HIFU. It isn’t harmful and shouldn’t affect your enjoyment of sex, but it might feel different to the orgasms you’re used to.

Talk to your doctor or nurse if you have problems with erections or other sexual problems. They can explain your treatment options and arrange free treatment on the NHS. They can also refer you to an erectile dysfunction (ED) clinic.

Urinary problems

HIFU can cause longer-term urinary problems. You may have some of the following problems straight after treatment, or they might develop some time later.

You may leak urine (urinary incontinence) after HIFU. This is more likely if you’ve already had external beam radiotherapy.
You may leak urine when you cough, sneeze or exercise (stress incontinence).
If your urethra, which is the tube you urinate through, or the opening of your bladder becomes narrow (a stricture), you may find it difficult to empty your bladder.
You may have a sudden urge to urinate (urgency).

Talk to your doctor or nurse if you have any urinary problems, as there are things that can help. There are things that can help, including lifestyle changes, pelvic floor muscle exercises and treatments. Your doctor or nurse may also refer you to an NHS continence service, run by nurses and physiotherapists who specialise in urinary problems.

A hole between the back passage and the urethra (rectal fistula)

Very rarely, HIFU can cause a hole between the back passage (rectum) and the urethra. This is called a rectal fistula. It affects fewer than 1 in 500 men who have focal or whole-prostate HIFU (less than one per cent). It is slightly more likely if you’ve already had radiotherapy.

Signs of a possible rectal fistula include:

urine coming out of your back passage
pain in your pelvis or back passage
bowel contents in your urine
air bubbles in your urine
urine infections, although these can be caused by other things.

Talk to your doctor or nurse straight away if you think you may have a rectal fistula. They may suggest waiting to see if the fistula heals by itself. You may have a catheter (a thin tube that drains urine out of your body) for about three months to give the fistula time to heal. Or you may need an operation to repair the hole.

What happens afterwards?

You will have check-ups with your doctor or nurse at the hospital at first, and then with your GP. This is often called follow-up. The aim is to:

check how your cancer has responded to treatment
deal with any side effects of treatment
give you a chance to raise any concerns or ask any questions.

You will have a PSA test every three to six months for the first few years to check how well the HIFU has worked. Your PSA level is likely to reach its lowest level a few months after HIFU. You may also have a prostate biopsy or MRI scan after treatment to check your prostate cancer has been treated successfully.

If you have focal HIFU, you might have low-risk cancer in another area of the prostate that is not treated on purpose. You will have regular tests to monitor the cancer that isn't treated. These might include PSA tests, MRI scans, and prostate biopsies.

After HIFU, your PSA level should fall and then stay low. A continuous rise in your PSA level can be a sign that the cancer has come back. If this happens, your doctor may suggest you have further tests, such as an MRI scan and a biopsy. Sometimes they might also suggest other types of scan, such as a CT scan, MRI scan or bone scan, to see if the cancer has spread to other parts of your body. If you need other scans, your doctor or nurse will tell you more about these.

If your cancer does come back after HIFU, you may be able to have further treatments that aim to get rid of it or control it. You may be offered:

Or your doctor may suggest monitoring your cancer, rather than treating it straight away.

Read more about what happens if your cancer comes back and what treatments might be available.

Questions to ask your doctor or nurse

What are the advantages and disadvantages of HIFU?
Where is this treatment available?
Can I see the results of HIFU treatments you have carried out?
What are my other treatment options?
Will I have focal HIFU or whole-prostate HIFU?
What are the side effects of HIFU? How likely am I to get them?
How can I manage any side effects I get?
How will I know if the treatment has worked?
How likely is it that I’ll need more treatment after HIFU?
What treatments are available after HIFU?

References

Updated: September 2015 | Due for review: September 2018

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