Common treatment options for men with localized prostate cancer include radical prostatectomy (retropubic, perineal, or laparoscopic [with or without robotic assistance]) and radiation therapy (external beam radiation therapy and brachytherapy). Less common therapies or management options are androgen deprivation therapy, cryoablation, watchful waiting, and active surveillance. Although these terms are not well defined in the published literature and have sometimes been used interchangeably, active surveillance implies a higher degree of monitoring, including PSA levels and prostatic biopsies, in order to guide the decision of when to intervene whereas watchful waiting implies a more passive approach focused on treatment of symptoms associated with disease progression. The choice of therapy depends on a number of factors, including cancer stage, histologic grade, presence of comorbidities, and patient preferences.

Focused Ultrasound Treatment

Focused ultrasound is a completely noninvasive, radiation free method to treat localized prostate cancer. Using this treatment modality in conjunction with image guidance, the physician directs a focused beam of acoustic energy to a selected volume in the patient’s prostate gland. The energy from the acoustic beam heats the targeted tissue at the focal point and creates a temperature elevation that thermally coagulates the targeted small volume of cells within seconds. This process is repeated until the entire selected volume or the entire gland is thermally destroyed. Several systems for focused ultrasound ablation of prostate tissue are available in various geographical regions, each differing in their guidance method (ultrasound vs. magnetic resonance imaging [MRI]) and type of transducer used (endorectal vs. intraurethral).

Benefits of Focused Ultrasound

The potential benefits of focused ultrasound for the treatment of prostate cancer include:

• It is a noninvasive, low morbidity treatment with a short recovery time and a quick return to work and the activities of normal life (usually the next day).
• A single therapy session is usually all that is required.
• It is reported to have a low complication rate, especially when considering post procedure impotence and incontinence.
• Focused ultrasound treatment does not use ionizing radiation, which means that it is possible to repeat treatment, it is possible to offer it as a salvage therapy for patients who fail radiation treatment, and it does not prevent pursuing other treatment options.

Patient Selection Criteria

Due to the fact that there are several devices with different technical limitations as well as different therapeutic approaches (transrectal vs. transurethral) and guidance systems (ultrasound vs. MRI), the selection criteria below are generalized with comments where relevant.

• The patient has been diagnosed with prostate cancer as confirmed by prostate biopsy.
• The prostate cancer is localized (visible on T1 or T2 images).
• Focused ultrasound is a first line therapy only if the patient is not a candidate for surgical treatment.
• Focused ultrasound is a salvage therapy option for a patient who experiences local recurrence after radiotherapy, radical prostatectomy, or previous focused ultrasound treatment.
• The patient’s prostate shows no calcification that induces an acoustic shadow.
• The patient has no permanent radioactive seed implants in the rectal wall.
• The patient does not have a urinary tract fistula or rectal fistula.
• The patient does not have an implant (stent, catheter) that is within 1 cm of the treatment area.
• For the transrectal approach, the patient must not have a rectal or anal fibrosis, a rectal or anal stenosis, or any anomalies that would make endorectal probe insertion difficult. Additionally, the patient must have no history of intestinal pathology.
• For the transrectal approach, the patient must have no anatomical anomaly of the rectum or anomaly of the rectal mucous membrane.
• The patient may not have an artificial sphincter, penile prosthesis, or intraprostatic implant (such as a stent).
• The patient must not have an active urogenital infection.
• For some systems, the patient’s gland size should not be bigger than 40 cc.
• Focused ultrasound treatments performed using MRI guidance are contraindicated in men with MRI-related issues (e.g., the presence of pacemakers or metallic implants that are incompatible with MRI, sensitivity to MRI contrast agents, or the inability to fit into the MRI bore).

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