Focal therapy is an advanced, minimally invasive treatment option for localized prostate cancer that targets cancerous lesions while preserving surrounding healthy tissue. By avoiding whole-gland treatment, the approach can minimize risks of common side effects associated with radical prostatectomy, including urinary incontinence and sexual dysfunction. In this video, Bruno Nahar, M.D., associate professor of urologic oncology at the Desai Sethi Urology Institute (DSUI), part of UHealth, the University of Miami Health System and the Eric and Elizabeth Feder Family Endowed Chair in Urologic Oncology Research, demonstrates focal therapy using the Focal One robotic high-intensity focused ultrasound (HIFU) platform to precisely ablate prostate cancer tissue.
UHealth’s Department of Urology launched its focal therapy program in 2015 and was among the first academic centers on the East Coast to adopt this innovative approach. DSUI recently completed 200 HIFU cases, placing the institute among the top five hospitals in the United States to reach this milestone. This video also highlights the patient experience and clinical decision-making involved in focal therapy, offering insight into an evolving treatment option for prostate cancer patients.
I'm Doctor Bruno Najar. I'm a urological oncologist here at the University of Miami, and today we'll be doing a, um, a HIFU case which HIFU stands for high intensity focused ultrasound. It's an alternative treatment for localized prostate cancer. This is actually a young patient, 52 year old. had a very localized prostate cancer, um, which we did a biopsy. I'm gonna show the images and the biopsy actually uh confirmed the diagnosis of prostate cancer, intermediate risk, so not a very aggressive type of cancer and, and amenable to focaltherapy. The whole concept of focaltherapy is essentially to treat the area where the cancer is and save the rest of the prostate, right? Compared to traditional treatments such as radiation therapy and, and radical prostatectomy. Um, focal therapy can potentially, uh, um, um. Treat the cancer and still um maintain a good quality of life for the patient. So that's that's the reason why this patient actually chose focal therapy because he's a very active young guy um with good um um erectile function, good urinary control. So he wanted to avoid the side effects from radical treatment. So that's why he came to us for focal therapy. So, I'm gonna show you now the images. So this is his MRI and as you can see here, so it shows here on the left side this dark spot right on the right side of the prostate and on the other sequences in the MRI it looks dark on what we call the ADC and bright on the DWI. Essentially it's just showing that this is the area where the cancer is. This is our ROI and exactly the area we're going to treat. The biopsy we did was a fusion biopsy, so we use. The MRI to guide our biopsy to do a targeted biopsy and, and it was positive. We do the target and we also sample the rest of the prostate, but the only area where the cancer was found is exactly in this spot. So we're gonna go ahead and and start the treatment. So the patient is already positioned and we have an ultrasound probe inside the rectum, uh, both for imaging and for, um, and for treatment. So we have to center the probe. We're gonna position the probe. Essentially what we're doing here, we're gonna do a sweep of the prostate to confirm, as you can see right there, the location of the tumor, which actually corresponds very well with the MRI it showed. He has a very small prostate which is again, uh, ideal for focal therapy. Small prostate, small uh tumor. So there's a lesion right there. That's nice. OK, so after we do the sweep of the prostate, we're gonna start our planning. So essentially what we're doing now, we're just measuring the prostate. It's part of the procedure so that we know how much tissue was actually treated. So this process at 27 cc, which is kind of a normal size, especially for his age. And here's where we start the planning. So we're gonna treat the pro this is the uh this is the apex of the prostate here. Um, and this is the base on this side, and that's exactly where, where the lesion is. We can clearly see it here, the lesion at the apex on the right side. So that's, we're gonna start with, we're gonna do two passages. The first passage, we're gonna do a very true like focal ablation where we're gonna blade the lesion with some safe margins, and then we're gonna do a second passage where we're gonna do what we call a hemigland. We're gonna treat almost the entire um right side of his prostate. That's to ensure a good cancer control. So as we go here, so that's our apex right there, see? Right there. On this side, apex is here. See the levators here? So that's where I'm gonna put my, that's where we're gonna put the a right there. And the treatment, again, we're gonna gonna have to start right here because we're giving. Yeah, it's actually pretty good. Almost 4 millimeter there of safe margins from the apex. So that's good. See, that's good. I mean, so good safe margins for cancer control. And then we'll do the same thing here. We're gonna do about 5, so we're gonna go all the way up here a little bit more cause it's very, so this is what we're gonna treat now. The, the, the, the first passage is gonna be a true focal. So it's gonna be basically this. OK, so once, uh, once we're done with the planning, this is actually, um, The, uh, we're gonna localize the lesion and actually plan the actual treatment for each slice. So essentially how it works is we cut the prostate in different slices, so each slice has 1.7 millimeters. So we're gonna plan exactly do what we call a confirmation of ablation um of that lesion. On and and confirm the location on each slice. OK, so we're going to start here. We can identify the rectum here. This green line is actually where the rectal wall is. These are the levator's muscle. Um, here you can see the neurovascular bundle on both sides. We try to preserve them because that, um, helps with the, with the, uh, functional outcomes and his erections after. So we're gonna start right here. The urethra is high, so we're gonna avoid, um, treating the urethra on this side. To avoid any side effects. OK, so we're gonna do this. And then as we move up. We're gonna change our plan. To cover. The entire right side here where the tumor is. OK. Yeah, now we can start to, we start to see the actual lesion. It's right here. Yeah, lesion is right there. So this um blue line. We're marking the area. It's gonna be treated and And the yellow line, the yellow line is actually. The area that is going to be treated, the effective area. You can see that all the time we we're we're able to actually spare important structures. So we're sparing the bundle that you can see the bundle on this side, we're sparing it. We're sparing the urethra, so that minimize side effects. So, we're gonna start the treatment for this initial block. We have a total of 3 blocks in this passage. And you can see that it's very precise. This artifact that you see is actually a machine shooting. So the way it works is it fires very precise um ultrasound waves to this specific spot, very focused, and then the energy builds up here. And can reach up to 95 to 100 °C and that destroys the cancer. You can see that we are actually sparing all the surrounding structures. So this is a very precise, minimally invasive procedure to treat prostate cancer. It's very common to see treatment uh effects here as you can see this, this white, uh uh uh shadow here. It's essentially um what we call the popcorn effect is That confirms to us that the that the energy that's being delivered to that area. We can start to see the lesion here on the right side. And once we plan, everything else is, is actually done robotically. So the machine actually um That's all the treatment once we, we finish the planning and it follows the instructions we gave them. So this first block is gonna take a total of um I think about around 3, 2-3 minutes. We have 3 blocks for this initial passion and then the second part is gonna be a little bit longer because we're gonna bleed more tissue. But it's a very fast procedure um and uh and a very dynamic. Dynamic too because I can stop if I feel like that I'm missing a spot or if the machine is not exactly accurate on where I wanna play like here, it did shift a little bit so I can pause and modify the contour and, and readjust my planning and then It automatically corrects and um and continue the treatment. Again, here's a nice view so you can clearly see the neurovascular bundle. We're preserving it. The lesion is far from the bundle. You can see the lesion on this posterommedial apex and you can see our planning. It's gonna cover the entire right side. So lesion plus safe margins and be sparing the urethra that you can see here on top. And on this side is a neurovascular bundle on the contralateral side. OK, so we're, we're done with the first passage, you know, we're gonna, we have to plan again for the second passage, the double tap. Um, the way we're gonna do it for the first passage, we, we only treat the, the lesion, right, with some safe, uh, margins. But now we're gonna treat, we're gonna extend the ablation zone to the, uh, to the, to the, uh, the right lobe, to the, the entire right lobe, what we call a hemigland ablation. Um, the reason we do it is when you give like really like the 1 centimeter margin of, um, for that specific lesion, it's gonna be almost like a hemi gland treatment because um of the location of it. Because it's apical, we might be able to save a little bit of the bladder, uh, the bladder neck, and the base of the prostate because that will minimize side effects as well. But we need to give for the second passage at least a 1 centimeter, uh, safe margins there. So, um. Again, so we're gonna identify the apex, which is right here, the anatomic apex, and then we can see the lesion again right there. The lesion is right here. And this is where we're gonna start our ablation. Yeah, right there, and we're gonna finish it. So let's see if we do. 1 centimeter margin and it's gonna be right here. So yeah, we can save some of the uh the base of the bladder which will, again, like I mentioned, minimize side effects. Irritated symptoms and obstructive symptoms. So we can finish here. Yeah, that's good. We go a little bit longer somewhere here. OK. This is gonna be due to. So on this screen here, what we have is, is kind of a like a a black box and essentially it tells us um what was already treated um and how many, how many blocks and slices we treated. So if any, if anything happens, right, I can go back here and see. Exactly what was treated and so let's say there's some uh technical or mechanical issue. I can stop the treatment and come back and redo it um and I know exactly where I finished uh I stopped the treatment and I can start from there. So this is kind of having like a a black box right here. So, this machine has also some uh safety features. One of them is um it auto it automatically detects where the rectal wall is so and stay away from it when it's firing. So that again, one of the concerns we always have is is the uh um you know, safety of the rectal wall. Uh we haven't had a single rectal wall injury. Or fistula during these cases, these primary cases and uh so one thing is that the other thing is um that there is you can see the probe temperature so there's a cooling system that goes inside the probe and you can see um it actually uh keeps the temperature in the rectum low, very low. So that also avoids any uh uh protects the rectum from any injury. Um, and, uh, and, and so, and also every time it fires, the, the alter, it keeps a safety distance when it auto detects the rectal wall, it actually keeps a safety distance from the wall to the area of the ablation. And you can see these three dots here, so. Every time it's fired, it, it they auto detect it and then they adjust the height of the probe depending on the location of the rectum on that specific spot. And there's a third safety feature which is a sensor so it can actually detect the patient because this is very precise. We're talking about millimeters. So if the patient moves, it detects the movement and stops the treatment. And that's also 11 important thing to discuss with anesthesia. Patients need to be fully paralyzed. They can't move. But this is the latest, uh, the, the latest uh machine and, uh, essentially it allows us, as I was mentioning, to actually do this confirmational ablation. In the past we didn't have a lot of room for, you know, to change the treatment, but this one allows us actually. To, to, uh, um, protect and spare much more of the important instructions than we used in the past, it also comes with a fusion software which means we can use the MRI we have upload it to the system and overlap exactly with this one, and then you can see exactly the overlay where the lesion is. This one is a very clear case, but sometimes it actually helps. There's also the feature that you can do in the end is to inject microbubbles. So microbubbles is essentially a contrast or, um, you know, ultrasound and uh so you can inject, inject it in the vein. And then you can actually see it if you see whether it's, you can see the bubbles inside of the ablated zone or not. Technically, if you destroy the tissue, there shouldn't be any bubbles, there shouldn't be any blood flow to that area, but if you see it, it's probably because um you, you, you didn't do a complete ablation. So in this, um, second passage, we have a total of 4 blocks. Each block has about, you know, 5 slices. So it's a slightly longer treatment as I, as I mentioned, we are doing a more extensive ablation on the second passage compared to the first one. Because our top priorities, of course, is cancer control, so. The more you ablate, the more energy you deliver, the better cancer control. So the patient has a Foley catheter in in terms of, um, you know, follow up, we, we send these patients home the same day. They go home with a Foley catheter because there's always swelling of the, he has a small prostate, no urinary symptoms, but there's always swelling of the prostate once you deliver energy to it. So we keep the Foley catheter until the whole inflammation uh uh cools down and then we can safely remove it without any, any retention. Um, so catheter, fully catheter for 7 days. We keep them on, we keep them a month on, um, Flomax, tamsulosin, which is to relax the prostate, and they also go home with, of course, painkillers, and but they usually don't have a lot of pain and, um, and antibiotics. And uh we for these particular patients with intermediate risk cancer we um we like to do uh an MRI followed by a biopsy in one year first to confirm that the area ablated is free of cancer and also to confirm that there's no uh other cancer elsewhere in the prostate, so essentially. Um, we finished the treatment, so we did two passages, as you can see here. This is the area we treated. The first passage was just the apex, and then the second passage we extended the ablation, so it's almost like a quadrant. That's it. Hope you enjoyed it.
