Have you ever used a magnifying lens to open up a tiny hole on a leaf? The same principle is also valid for HIFU.

HIFU uses sound as the source of energy instead of sunlight. HIFU is a transducer to direct and focus energy instead of a magnifying lens.

What is HIFU treatment?

High-intensity focused ultrasound (HIFU) uses high intensity ultrasound energy to destroy cancer cells in prostate. A beam of ultrasound energy reaches prostate via a probe placed in anus (rectum).

High-intensity sound waves form heat by focusing on a specific point. Given on a specific location in the body, HIFU energy reaches up to approximately 195 degrees Fahrenheit in just a few seconds on the focal point. Thus the cancer tissue is destroyed without radiation or any surgical operation in the body, while the tissue besides the focal point remains unharmed. By this means intended treatment is given without harming the healthy prostate tissues surrounding the focal point.

This minimally invasive procedure is provided as an outpatient treatment.

When treating prostate cancer with HIFU, the technique allows for the precise targeting of specific cancerous regions within the prostate, along with a small margin of surrounding healthy tissue. This is achieved through overlapping bursts of ultrasound energy, effectively ablating the desired area. HIFU can be applied to the entire prostate gland or, more commonly, to one or two localized cancer zones. While full-gland HIFU is still used in select cases, it has become less frequent. Instead, focal HIFU — which targets only the cancerous sections of the prostate — is now the preferred approach. This method is conceptually similar to a lumpectomy in breast cancer, aiming to remove only the affected tissue. Compared to whole-gland treatments such as radiation therapy or prostatectomy (surgical removal of the prostate), focal HIFU results in fewer side effects and enables a faster return to everyday activities.

How Effective Is HIFU in Treating Prostate Cancer?

Between 20% and 30% of patients, depending on their cancer’s risk level at the time of diagnosis, may require a second HIFU treatment in the same area within a 6 to 7 year period. The likelihood of this depends on the aggressiveness of the cancer at the initial treatment stage. We consider this second procedure to be an expected part of the focal therapy approach. Many patients view the possibility of repeating HIFU as a benefit rather than a drawback, and we advise those opting for focal therapy to be aware that additional sessions may be necessary. On average, around 3% to 5% of patients develop new tumors in parts of the prostate that were not treated initially. These can be addressed with another round of HIFU, a different focal therapy, or patients may choose to move forward with surgery or radiotherapy at that point. Overall, about 5% to 10% of patients will eventually require surgery or radiotherapy due to cancer recurrence, even after two HIFU sessions. The risk of the cancer spreading beyond the prostate remains very low, and prostate cancer-related death following HIFU is extremely rare—comparable to outcomes seen with surgery or radiation.

Who Is a Good Candidate for HIFU in Prostate Cancer Treatment?

Most patients receiving HIFU for prostate cancer have intermediate-risk disease, meaning the cancer remains confined within the prostate and typically has a Gleason score of 3+4=7 or 4+3=7. These are generally classified as ISUP Grade Group 2 or 3. If the cancer is limited to one or two distinct regions and there are no other medical concerns preventing treatment, these patients are considered ideal candidates for HIFU. In certain cases, small high-risk cancers or those located at the edge (capsule) of the prostate can also be treated; in the UK, roughly 10% of HIFU procedures are performed in high-risk cases.

Often, patients have a dominant tumor known as the “index lesion,” which, based on extensive biological research, is the main driver of the cancer’s behavior and progression. Many men also have very small, low-risk tumors (with a Gleason score of 3+3=6) that are not visible on MRI. These are referred to as indolent cancers and are commonly found in about one-third of men over the age of 50. HIFU treatment typically focuses on ablating the index tumor while closely monitoring the low-risk areas, as these usually remain stable and can be tracked over time. Treating every visible lesion regardless of risk would make the treatment more similar to whole-gland therapy like surgery or radiotherapy, reducing the benefit of fewer side effects and complications.

For some patients whose tumors are suitable for HIFU but located in technically challenging areas—such as the anterior prostate or in glands with intervening fat or tissue between the prostate and rectum—Professor Bakir may recommend alternatives like IRE (Irreversible Electroporation) or cryotherapy to ensure more effective energy delivery.

Additionally, HIFU may be considered for patients with low-risk cancer who are either unable or unwilling to continue with active surveillance, or who show disease progression during monitoring. However, in most cases, treatment for anxiety alone is discouraged—HIFU, surgery, or radiotherapy should not be used solely to ease worry unless there is clear evidence of cancer progression. On the other hand, patients diagnosed with high-volume low-risk cancer that is visible on MRI are more likely to progress during surveillance. For them, focal therapy such as HIFU may be a reasonable and proactive treatment option.

Is HIFU an Alternative to Surgery (Prostatectomy) or Radiotherapy for Treating Prostate Cancer?

HIFU may be considered for patients who require active treatment to prevent their prostate cancer from progressing, as long as the disease is confined to one or two specific regions within the prostate. It’s essential that there is no evidence of the cancer spreading beyond the prostate, also known as metastasis. Typically, individuals with localized prostate cancer are offered whole-gland treatments like radical radiotherapy or surgical prostatectomy, which involves removing the entire prostate. These options are proven to be effective and can enhance long-term cancer control and survival. However, in many cases, the overall benefit over careful monitoring is modest.

Whole-gland treatments such as surgery or radiotherapy, while effective, can harm nearby healthy tissues. This includes the neurovascular bundles responsible for erections, as well as the nerves and muscles that help control urination. The urethra, which passes through the prostate, may be affected, leading to urinary symptoms like increased frequency, urgency, or discomfort. The bladder, located close to the prostate, can also be irritated during treatment, causing similar issues. Additionally, the rectum lies just millimeters behind the prostate, and radiation exposure can result in bowel-related symptoms such as rectal discomfort, bleeding, or loose stools.

After radical prostatectomy, long-term urinary incontinence (requiring at least one pad per day) affects around 15% to 25% of men, with 5% to 10% needing more than one pad daily. These figures are higher in the initial 6 to 12 months post-surgery. Erectile dysfunction rates vary depending on the degree of nerve preservation, but it typically impacts 30% to 60% of patients. All patients will lose the ability to ejaculate, and those who regain erections may still require medications, injections, or vacuum devices. Roughly 5% of patients develop narrowing at the connection point between the bladder and urethra (the anastomosis site).

In contrast, long-term urinary leakage after radiotherapy is less common, affecting fewer than 5% of patients. Still, other urinary symptoms may occur, such as urgency, increased frequency, nighttime urination, and pain, largely due to radiation-induced irritation of the bladder and urethra. Around half of patients experience long-term erectile dysfunction, and most are unable to ejaculate. Side effects from radiotherapy also include bowel symptoms, with approximately 5% experiencing severe issues like bleeding and discomfort, and another 5% to 10% experiencing mild to moderate symptoms. Brachytherapy, a form of radiotherapy that uses radioactive seeds implanted directly into the prostate, comes with its own unique risks to urinary, sexual, and bowel function. Other forms like stereotactic or proton radiotherapy haven’t yet shown convincing evidence of reduced side effects or improved results, although they typically require fewer sessions.

As such, HIFU offers a potential alternative for eligible patients who want to avoid the side effects of full-gland surgery or radiotherapy. It is not suitable for every individual with prostate cancer. A thorough discussion with a specialist in focal therapy is essential to determine if HIFU is appropriate. It’s important to note that physicians who don’t specialize in focal therapies may mistakenly assume a patient is not a candidate, so it’s advisable to seek a consultation with a clinician experienced in HIFU and similar treatments.

Can HIFU Replace Active Surveillance in the Management of Prostate Cancer?

For men diagnosed with prostate cancer that hasn’t spread and is classified as low-risk—or in some cases, a small amount of intermediate-risk cancer—active surveillance is typically the preferred management approach. This involves close monitoring of the disease through regular PSA blood tests, physical examinations, MRI scans, and occasional biopsies. For these patients, active surveillance is a safe and effective strategy, as most low-risk prostate cancers do not grow or spread, and small-volume intermediate-risk cancers tend to grow very slowly.

In general, active treatment (such as surgery, radiotherapy, or HIFU) is not recommended as an alternative to surveillance for men with confirmed low-risk prostate cancer who have undergone a thorough evaluation, including a high-quality multiparametric MRI and targeted plus systematic prostate biopsies. However, men with intermediate-risk prostate cancer do have several treatment options: they can continue with surveillance, choose focal therapy such as HIFU, or opt for whole-gland treatments like surgery or radiotherapy. The decision depends on the patient’s individual preferences and discussions with their medical team.

That said, some men with low-risk disease may find the idea of living with cancer—even one that is unlikely to cause harm—emotionally difficult, despite reassurances. Others may not tolerate the repeated PSA tests, MRI scans, and potential biopsies involved in active surveillance, and over time may feel the burden of monitoring is too great. Additionally, a minority of patients will eventually show signs that the cancer is progressing and require treatment.

In all of these situations—whether due to psychological stress, fatigue from surveillance, or actual disease progression—active treatment becomes a consideration. For most of these men, HIFU is one of the available treatment choices, alongside radiotherapy and surgery.

Can I Have HIFU Again if Needed?

If prostate cancer returns or remains after the initial HIFU treatment, most patients are eligible for a second HIFU session targeting the same area. In certain cases, due to the location or shape of the tumour, Professor Bakir may recommend alternative focal therapies such as IRE (Irreversible Electroporation) or cryotherapy instead. Additionally, if new cancerous lesions appear in areas of the prostate that were not previously treated, many patients opt for another round of focal therapy (HIFU, IRE, or cryotherapy) specifically for those new sites. At any stage, patients still retain the option to pursue surgery or radiotherapy as alternative treatments.

What If HIFU Doesn’t Work—Can I Still Have Surgery or Radiotherapy?

Yes. If HIFU is not successful, both surgery (prostatectomy) and radiotherapy remain viable options. Performing surgery after HIFU can be somewhat more complex because of scar tissue created by the earlier treatment, but since most of the prostate remains unaffected, experienced surgeons generally find this procedure manageable. In fact, they often report that surgery after HIFU is easier than surgery following prior radiotherapy, which can make tissue planes more difficult to navigate.

The risk of erectile dysfunction is typically higher with salvage surgery (surgery after HIFU failure), but the risk of urinary incontinence appears to be similar to surgery performed as a first-line treatment.

Radiotherapy after HIFU is also an option and is generally well tolerated. Experts have found that it does not significantly increase the risk of urinary incontinence or erectile dysfunction when compared to radiotherapy given as the initial treatment.

A Note on Recurrence

It’s important to recognize that no prostate cancer treatment offers a 100% guarantee of cure. For example:

• 10% to 20% of patients who undergo surgery may later require radiotherapy or hormone therapy due to recurrence.
• Similarly, 10% to 20% of those treated with radiotherapy may need additional interventions such as hormone therapy, surgery, or focal therapies like HIFU, IRE, or cryotherapy.

While treatment failure is always a possibility, cancer-specific survival outcomes are similar across all major treatment options—whether you choose HIFU, surgery, or radiotherapy.

What Happens in the Days Before and On the Day of HIFU Treatment for Prostate Cancer?

Before Treatment:
In the days leading up to your HIFU procedure, you will meet with the administrative and nursing team who will update your medical records to ensure there are no new issues that the anaesthetist or surgeon need to consider. You will also have the opportunity to meet Professor Dr. Baris Bakir and the surgical team. During this meeting, the formal written consent process will take place, and any remaining questions you have will be addressed.

On the Day of Treatment:
HIFU treatment is performed under general anesthesia, so you will be fully sedated. If for health reasons general anesthesia is unsuitable, spinal (epidural) anesthesia may be used to numb the lower body.

During the procedure, you will lie on your back with your legs apart or on your side with your knees pulled towards your chest. At the start, a catheter—a thin tube inserted through the penis into the bladder—will be placed. The surgeon will then insert an ultrasound probe into your rectum to guide the treatment.

The surgeon will carefully plan the treatment and deliver multiple HIFU pulses. Each pulse targets a small area of the prostate (approximately a 10x3mm cube), heating and destroying the cancer cells. Professor Bakir uses the Sonablate machine, made by Sonacare in the United States, which allows real-time adjustments to the power and focus of the ultrasound based on live ultrasound imaging. This dynamic control has been shown to improve treatment effectiveness compared to other machines that rely solely on preset computer protocols.

Thanks to specialized fusion software, the exact location of the lesion seen on MRI is displayed during treatment in real-time, allowing precise targeting and ablation of the cancerous area. This accurate localization provides a significant advantage.

Experience is critical to successful HIFU outcomes and minimizing side effects. Professor Bakir is highly experienced, having performed over 300 cases in the last five years.

The entire procedure usually takes between 1.5 and 2.5 hours, depending on prostate size, tumour size, and the total treatment area. The time can also vary based on how much the prostate heats up and how often the surgeon must pause to allow cooling.

After Treatment and Catheter Management

The catheter may cause a sensation of needing to urinate because its balloon tip stimulates bladder pressure sensors. This sensation usually decreases over time but may persist until the catheter is removed, typically 7 to 9 days after treatment. In some cases—such as after HIFU post-radiotherapy, treatment of a large prostate, or extensive tissue ablation—the catheter may stay in place for 10 to 14 days to reduce the risk of urinary retention.

Side Effects of HIFU Treatment for Prostate Cancer

“COMPLICATION RATES STRONGLY DEPEND ON THE LOCATION AND SIZE OF THE PATIENT’S LESION, AS WELL AS THE OPERATOR’S EXPERIENCE.”

Early Side Effects (Immediately After Treatment and First Weeks):

• Tiredness and Lethargy: Patients may feel tired from the anesthesia right after treatment and may continue feeling fatigued for 1-2 weeks as the body heals. This is normal.

• Urinary Symptoms:
  • Urgency, frequency, getting up at night to urinate
  • Discomfort or burning when passing urine
  • Slower urine flow due to prostate swelling and inflammation
• These urinary symptoms typically improve over 6 to 8 weeks but can take up to 3 months in some patients.
• Most patients can return to desk-based work after 2-3 weeks and should avoid strenuous activities or abdominal pressure for the first 4 weeks, gradually resuming over the next 2-3 weeks.
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• Blood in Urine: Occasional blood, blood clots, or tissue debris in urine is common as the body expels dead prostate tissue, similar to how a scab forms on a skin wound.
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• Infections:
  • Urinary tract infections requiring antibiotics can occur.
  • Rarely, infections in the testicle (epididymo-orchitis) may develop.
  • Very rarely, infections may require hospital admission for intravenous antibiotics.

Rare Complications Related to Surgery or Anesthesia:

• Chest infections
• Blood clots in legs (deep vein thrombosis) or lungs (pulmonary embolism)
• Preventive measures such as compression stockings and blood-thinning injections during surgery are standard.

Long-Term Side Effects:

• Urinary Incontinence:
  • Risk of needing to wear at least one pad daily is about 1 in 200-500 (0,2-0,5 %).
  • Risk may be higher if the tumor is near the urinary sphincter muscle; your doctor will advise if this applies.
  •  
• Erectile Dysfunction (ED):
  • Risk varies from 5% to 15% depending on how much prostate tissue is treated and baseline erectile function.
  • Patients with good baseline function have a 5-10 % risk; those with poorer function have a 10-15 % risk.
  • Treating both sides of the prostate roughly doubles the risk.
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• Dry Orgasm (No Seminal Fluid):
  • Average risk is about 15-20 %.
  • High risk if both sides are treated or the treatment is close to the middle prostate where seminal fluid tubes join.
  • Even when fluid is present, volume is usually reduced.
  • If fluid is present, it may contain viable sperm—contraception should be used if pregnancy is not desired.
  • No current effective treatment for dry orgasm.
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• Bowel or Rectal Problems:
  • Long-term bowel problems are very rare.
  • Some patients may experience constipation or bowel upset shortly after treatment, usually resolving quickly.
  • Very rare (1 in 1000 – 0,1 %) risk of recto-urethral fistula (a hole connecting the rectum and urinary tract).
  • If a fistula occurs, long-term catheter drainage is required for healing; surgery may be necessary if healing does not occur.
  •  
• Urethral Narrowing (Stricture):
  • Occurs in about 0,1-1 % of patients.
  • May require surgical removal of necrotic tissue or scar tissue through a cystoscopic procedure under general anesthesia.

Follow-Up After HIFU Treatment for Prostate Cancer

One to two weeks after treatment, your catheter will be removed by the medical team. Most patients experience a drop in PSA levels ranging from 20% to 90% compared to baseline. The degree of PSA reduction depends on factors such as the amount of inflammation in the prostate (which can raise PSA), the volume of ablated tissue, and how much the cancer contributed to the PSA before treatment.

A small minority of patients may see no PSA drop or even a rise at the 3-month mark, usually due to ongoing healing and inflammation. In such cases, Professor Bakir may recommend repeating the PSA test 2 to 3 months later, often after a short course of anti-inflammatory medication to reduce prostate inflammation.

If PSA levels show a good response, the next PSA test and MRI scan are generally scheduled around 12 months after treatment. Healing can take 6 to 9 months, so earlier imaging may be inaccurate due to inflammation or necrotic tissue.

If residual cancer is detected at 12 months, most patients will undergo another HIFU session. If no residual or new cancer is found, you will continue with 6-monthly PSA tests and annual reviews with Professor Bakir.

MRI scans after focal therapy should be interpreted by radiologists experienced in this area to ensure accuracy.

PSA levels may fluctuate over time; small changes without an upward trend are normal. If PSA rises, repeating the test in 2 to 3 months with a short course of anti-inflammatories (like ibuprofen or naproxen, if appropriate) or antibiotics may help clarify whether inflammation is the cause.

If recurrent cancer is confirmed, further focal treatments such as additional HIFU, IRE, or cryotherapy can be performed, focusing only on the cancerous area, not the whole prostate. IRE or cryotherapy may be preferred in cases with significant scar tissue or where the tumour location makes HIFU technically difficult.