HIFU my procedure and lead up
I was diagnosed with prostate cancer just by accident. I was in my family physician’s office for shoulder problem and I happen to notice in her office a plastic mount of the longitudinal section of a human male pelvis. I have a Ph.D in Zoology so I was interested in what the write up was about. So, I began to read about enlarged prostates and symptoms. I quickly began to realize that I had a prostate problem with intermittent urine flow and weak stream. I discussed these issues with her and she booked a blood test in Feb 2007. I discovered that the prostate was quite large but the PSA (prostate specific antigen) was only 3.3, not a problem. I was referred to an orthopedic surgeon and discovered that I need to have my right shoulder’s rotary cuff repair. After the surgery the enlarged prostate began to swell probably due to the drugs I had to take for the post operative care. The prostate closed off the urethra and within two days I was in the emergency room having a catheter inserted which I had to keep in place for five days. My family physician referred me to an urologist. The urologist routinely had a blood test done to check the PSA and had scheduled a scoping of the prostate through the urethra within a week or two. The blood test for the PSA was done in July, 2007 Several weeks later I had the scoping done but in the interim my family physician received the report on the PSA reading from the urologist’s office and contacted me saying “Your PSA is high and the urologist will likely want to have a biopsy done.” After the procedure I asked the urologist about the PSA reading but he did not know anything about it. He checked with his office about my results from the PSA testing that he had ordered and his office contacted me to let me know that they had booked a biopsy for me to be done in about two months.
A week after the biopsy, I received a phone call from the urologist’s office informing me that I had prostate cancer and that I had an appointment the following Monday with the doctor to discuss my options. His office stated that this type of cancer was completely treatable but nothing else. When I got to the doctor’s office, the urologist came into the room and asked me what treatment I wanted. I asked for information on the possible treatments and their advantages and disadvantages only to get a reply that I was informed by his office so that I could look on the internet and research what my option were. The best that I could get from him was that there are two basic types of treatments –surgical removal and radiation treatment. He would not give me any information as to which was better or what are the side effects of each type of treatment. Due to my zoological background I was quite familiar with the anatomy of the male reproductive system, the accompanying structures, their positions in the body and the possible damage that could occur from any invasive procedure. I point blank asked about the differences between the two procedures with regard to problem of incontinence and erectile function but he stated that they are just the same and indicated that it was my decision. No further information would he offer me. I later found out from another urologist that radiation therapy is not recommended for a man of my age, 60 years old. Instead it is used for much older men (in their eighties) as the peripheral damage to tissue would not be a problem; assuming that these men would have died before the problems from that type of procedure would become an issue—not a pleasant prespective.
This had all taken place in September, 2007. I decided to look on the internet since that was the only thing this urologist offered and I stumbled upon the HIFU, specifically the Ablatherm. After reading the information on this procedure I decided to go with this method as it offered the least peripheral damage from the procedure. Incontinence was considered to be 5% of only type 1 and 2 incontinence which means that one would dribble a little urine when one would put a strain on the abdomen like golfing or lifting heavy weights. Erectile dysfunction was down to 20% or less when the nerve bundle sparing procedure was implemented. This procedure is always done unless there is an issue with the nerve bundles being to close too the prostate then it may not be possible. As far as I could ascertain, it seems as if all the Ablatherm procedures incorporate the nerve bundle sparing technique.
I contacted the Toronto Albatherm and after some discussion my prostate which measured 72cc had to be reduced to 40cc. This was to be accomplished by the use of hormone therapy. Dr. O prescribed Zoladex implant and Casodex pills for ten weeks but I had to get my urologist where I lived to prescribe this treatment. I was surprised and happy that my urologist agreed to do it even though he did not want anything to do with the post operative care or anything at all to do with HIFU. At the end of 9 weeks I needed to have the prostate measured. So I arranged to get it measured and on December 20th, 2007 the procedure was performed. My prostate size was reduced to 45.5cc good but not low enough yet. So, after a brief discussion with Dr. O I was to continue the Casodex treatment for one more month and get measured again. Unfortunately, the prostate did not reduce very much at all, only one cc less. Dr. O changed the prescription to Avadart and I was on the combination of Avadart and Zoladex for 6 weeks. At the end of the 6 weeks the prostate was measured and again only dropped one cc and now measured 43.5cc. In all cases three sets of measurements were taken and three volumes of the prostate were calculated. The numbers I have given are the average of those three volumes. The prostate measurement was still too high but when I contacted Toronto Dr. O mentioned that they were getting a new probe which would allow them to do larger prostates. The smallest dimension of my prostate was 38mm which was the upper dimension limit of the new probe. I decided not to go with the Ablatherm as I did not want to take the chance of having to undergo the procedure a second time. Dr. O’s stats showed that he had only needed to redo the treatment in two cases in over 300 so his results were excellent but again with my prostate size at the upper limit I felt that would increase my chances significantly of needing a retreatment.
While this was going on I continued to search the internet about treatment options and symptoms to see if something could have alerted me to the problem earlier; pain during ejaculation was one thing I had but did not realize it was an issue. In my search I came across the Sonablate system and was amazed that it had so many locations in the US and Mexico and even one in Toronto as well. I contacted the US HIFU and discovered that they were opening three more treatment centers in Canada: Winnipeg, Niagara and I think Montreal. The Winnipeg center was within a 7-hour drive for me and so no plane flight needed. I was apprehensive about this technique as I got the impression that the doctor was moving the probe manually within the rectum for each treatment. After talking to the nurse at US HIFU she made me aware that the probe in only adjusted by the doctor in order to get a complete image of the prostate. After that the probe moved mechanically within a cylinder within the condom filled with cooling water. Unlike the Ablatherm which moved back and forth in the rectum for each plane of treatment the Sonablate probe did not move again only the transducer moved in its cylinder. Also the Sonablate system has continuous monitoring of the prostate image during the procedure so that changes can be made due to the swelling of the prostate once the burning process has started.
The nurse took my phone number and passed it to Dr. D in Winnipeg saying he would contact me later that day. That evening I received his phone call. He spent over half an hour talking to me and my wife answering questions and giving information about the procedure. I decided to go with this procedure feeling that it was even better than the Ablatherm. After reading Internet testimonials on the HIFU message site about sedation options I realized that I could get a spinal and avoid the sedation since any sedative or anesthetic tends to knock me out for a very long time. I contact the Maples Surgical unit, where the HIFU treatment was to take place and arranged to have the anesthesiologist contact me. That same day I received his phone call and we talked about my sensitivity to anesthetics and I was able to arrange to have no sedation administered.
Before I left for Winnipeg I needed to get my prescriptions for use after the procedure as well as a pair of anti-embolism stocking—thigh high. I went to a drug store with the idea of just picking up a pair off the counter. To my surprise there were several tensions of stocking and I had to get measured in order to get the right size. I checked back with US HIFU for specifics on tension of stocking. I was to get the lowest tension—16 to 20mm of Hg (mercury). I went back to the drug store to be measured. The drug store did not have the correct one in stock but the store would order them for me and they would arrive within a week. I still had plenty of time to wait for the order which arrived in 8 days. Now, I had everything I needed for the procedure—the four prescriptions and the anti-embolism stockings.
I arrived in Winnipeg by myself due to some mix up. My wife was initially going to accompany me but the person who was going to look after our place could not do it at the last minute so I contacted the US HIFU to see if it would be okay for me to come alone since I was not going to have any sedation which seemed to be alright. Unfortunately, upon my arrival I discovered that legal issues make it essential that all patients must be accompanied by an adult. Everything is set for the procedure with a number of HIFU personnel having been flown in to assist the doctor. The administrator of Maples Surgical Center did some scrambling and was able to arrange through some business to have someone stay with me for the next 16 hours after my procedure. So, my treatment day remain as scheduled.
Just before the procedure I met with the doctor and the anesthesiologist and the nurses. The doctors informed me that I must be perfectly still during the procedure as the machine takes very minute strips of prostate tissue and burns it with the ultrasound. The Sonablate machine is very sensitive to any movement as it could change the position of the probe and not hit the target prostate tissue. The anesthesiologist stated that he would not give me sedation but because the procedure can take several hours I might have some discomfort lying in one place for so long, so all I would need to do would be to ask and he would give me a very small amount of the sedation just enough to eliminate the discomfort but should not put me to sleep. As it turned out I was on the table for 5 hours and did not need any sedation. I must admit that keeping still was not as difficult as I thought that it might be. I was not supposed to move even my arms.
The first step of Dr. D was to measure my prostate, and low and behold the prostate measured 34.5cc. I was not taking any treatment other than I still had the Zoladex implant. This measurement left me with a very unusual feeling in that God wanted me to have the Sonablate HIFU system because if my prostate measured 34.5 cc I would have gone to Toronto. The Winnipeg center did not open until February, 2008 and I had started the process of getting prepared for the procedure in October, 2007.
The Sonablate HIFU divides the prostate into six blocks in three tiers so that the treatment strips are short and much easier to get into the smaller areas of the prostate. My cancer was centered in the apex of the prostate where the capsule is thinnest and folds so some cancer cells could escape. Dr. D completed the treatment but wanted to make sure that no cells were missed in the small neck of the apex. He stated that the hormone treatment should have destroyed any cancer cells that might have escaped as those cells require testosterone to live but the stem cancer cells within the prostate would not die with a lack of testosterone, so, he created a seventh block (which is possible since the treatment strips are much smaller then the Ablatherm) in the very apex to clean out anything that was there.
After the procedure I was able to get dressed and sit in a recliner chair until my escort arrived. I did run into some problems with pain later in the day but Dr D and the administrator of Maples Surgical unit were keeping in contact with me. Dr. D tried to phone me the next day but I was not in the original motel room that I had stated. However, I had Dr. D’s cell phone and was able to contact him and he quickly replied to make changes and prescribe pain killers for me. Even after I got home I was able to contact Dr. D and he continued with a follow up. He also made arrangements to have another urologist available in my city that I could contact if problems arose. The pain killers eliminated my pain problems within a day or two and after a week I no longer require them.