Monday, March 22, 2010


We had a 71 year old gentleman coming from Bengal who had organ confined carcinoma prostate. He was a known case of asthma on regular nebuliser and steroid inhalation. He had very poor Pulmonary Function Tests parameters. The prostate was 40 cc and digital rectal examination revealed no nodularity or lateral wall spread.The biopsy revealed 3+3 Gleason score. So this gentleman was considered for the HIFU (High Intensity Focussed Ultrasound) for the prostate carcinoma. This is a new option for men with well differentiated organ confined Prostate Cancer. (This means a single tumour inside the prostate or several tumours but all on the same side of the prostate gland).The patient usually selected are Serum PSA less than 10 ng/ml, Gleason score less than or equal to 6 and the clinical stage of T1 or T2 a. As there is no such thing likes perfect prostate cancer treatment the physician has to do perfect balancing act in between cancer control and the quality of life. The radical surgery and the radiotherapy can sometimes cause impotence and incontinence and seriously damage the quality of life of the patient. HIFU: It uses a high energy focused ultrasound beam, which is directed across the wall of the back passage into the prostate to heat and destroy a very precise volume of tissue. HIFU MACHINE High Intensity Focused Ultrasound, or HIFU, is a therapy that destroys tissue with rapid heat elevation, which essentially "cooks" the tissue. Ultrasound energy, or sound waves, is focused at a specific location and at that "focal point" the temperature raises to 90 degrees Celsius in a matter of seconds. Over 7000 men, in nearly 100 HIFU centers worldwide, have already chosen HIFU with the Sonablate® 500, because it is the most advanced HIFU therapy available. The good part of HIFU is that; it avoids or reduces the damage to surrounded structures such as the muscle controlling urine flow and the nerves controlling erections whilst still suffering cancer control (which is a possibility after radical prostatectomy or radical radiotherapy-other two main options to cure prostate cancer). This means the patient can have a treatment for your prostate cancer without all of the associated side-effects with other treatments. The benefits of HIFU: - Rapid return to normal life after treatment - Almost 100% of patients maintain sexual potency - No incision is required which avoids the risk of surgical infection - The procedure can be repeated as necessary All men are followed up after HIFU with PSA tests every three months. If the PSA rises then further diagnosis is undertaken, but for approximately 90% of men treated, HIFU should be the only treatment required. If further treatment is required this is usually a further HIFU treatment, though any of the traditional treatments including surgery and radiotherapy are possible after . Contra-indications for HIFU:  Patients with Prostate Cysts more than 10 mm  Patients with calcifications greater than 10mm  Prostate Stents  Active Bacterial prostatitis  brachytherapy seeds  Patients on anticoagulation therapy  Rectum cannot accommodate 2 fingers dilatation Procedure: The patient was anesthesized with an epidural anaesthesia to prevent pain and movement. The patient was taken up for LASER prostatectomy to to evaporate the prostate basically to downsize the prostate so that HIFU can treat the whole prostate effectively in two zones only. Then HIFU probe was introduced in the rectum and the prostate anatomy was mapped .The prostatic tissue was divided in two zones and HIFU treatment was carried out. It took 3 hours for whole treatment including the LASER vaporization of the prostate. At the commencement of the procedure a suprapubic catheter was inserted through the patient´s lower abdomen and into the bladder. This catheter, which was kept as precautionary measure to prevent urinary retention because sloughed prostatic tissue blocking the prostatic urethra. The suprapubic catheter was clamped on day 3 to see whether the patient can void and the patient voided very well. The next plan to observe his urinary stream for 2 more days and then remove the suprapubic catheter if everything goes on well. OUTCOME OF HIFU: 94% BIOCHEMICAL FREE DISEASE RATE AT THE END OF 4 YEARS AND 87% BIOPSY NEGATIVE RATE AT THE END OF 6 MONTHS. Scientific background for HIFU: Uchida et al conducted a study on 63 patients (published in British Journal of Urology (2006) who underwent HIFU for organ confined prostate cancer. The mean follow-up was for 23 months (3 – 63 months), and all patients had biopsy at 6 months. The 3 year biochemical disease free rate (ASTRO) in all patients was 75% after 3 years. The Biopsy after 6 months was negative in 87% of patients. The Incontinence rate was 1% , Fistula rate 1, Stricture rate 24 % ( managed by office dilatation )


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