happy middle aged patient with docotor

What is Focal Therapy?

Focal Therapy is a form of localized treatment targeting areas of the prostate that have either prostate cancer cells or inflamed tissue from BPH (Benign Prostate Hyperplasia).

What is Focal Therapy for Prostate Cancer Treatment and BPH?

NBC Nightly News recently reported that many men with prostate cancer are delaying surgery and radiotherapy, instead choosing active monitoring. Active monitoring is when a patient takes a wait-and-see approach while doing regular blood work and check-ups with their physician to monitor the state of their prostate cancer.

While active monitoring is a viable option for early-stage prostate cancer in place of conventional surgery and radiotherapy, the news report failed to mention a brand new treatment option: Focal Therapy.

Dr. Kia Michel at Comprehensive Urology recently performed the first TULSA-Pro Treatment in Beverly Hills, CA. A form of focal therapy, the Tulsa Procedure is able to specifically treat cancer cells in the prostate with minimal impact to the surrounding, healthy tissues. Dr. Michel has performed more combined focal therapy treatments (TULSA & HIFU) than any other physician in California.

What Forms of Focal Therapy for BPH & Prostate Cancer Treatment are Available?

The two primary forms of Focal Therapy for BPH and Prostate Cancer are TULSA and HIFU.

TULSA (Transurethral Ultrasound Ablation)

TULSA is a promising new treatment option for prostate cancer. This form of focal therapy uses high-intensity ultrasound waves to heat and destroy cancerous tissue within the prostate. This treatment method allows for more precise targeting of the cancerous cells—which drastically minimizes damage to the surrounding healthy tissue.

While TULSA is a relatively new treatment, and is still being studied, early results show improved outcomes for cancer control when compared to more traditional approaches, like surgery and radiation. Another huge benefit of TULSA is preservation of urinary and sexual function, both of which can be impaired by traditional cancer treatment methods.

HIFU (High-Intensity Focused Ultrasound)

HIFU is another non-invasive focal treatment option for prostate cancer. As the name suggests, HIFU uses high-frequency sound waves to destroy cancerous tissue. Similar to TULSA, HIFU has a shorter recovery time than traditional cancer treatments and is much less likely to result in erectile disfunction or urinary incontinence.

How is Focal Therapy Done?

Since Focal Therapy is a broader term encompassing several different cancer treatment procedures, it’s important to talk to your provider about which type of Focal Therapy treatment they suggest for you, and how it is performed.

TULSA uses a catheter—which is inserted through the urethra, rather than incisions—to deliver the waves directly to the prostate.

During the HIFU procedure, on the other hand, an ultrasound probe is inserted into the rectum. From this location, focused beams of ultrasound energy are delivered to the prostate gland. The heat from the ultrasound energy destroys the cancerous tissue while leaving surrounding healthy tissue intact.

HIFU and TULSA therapies are typically performed at outpatient centers, meaning no costly, time-consuming hospital stays.

What is the TULSA Procedure (TULSA-PRO)?

The TULSA Procedure is a personalized, minimally invasive approach that avoids radiation and incisions, making it one of the latest non-surgical advancements for treatment of both prostate cancer and an enlarged prostate. Its unique design allows for customizable treatment to suit your unique situation. This customization also improves the preservation of both penis and prostate function.

When used by an expert, this system can effectively destroy cancerous cells or irregular tissues while simultaneously preserving healthy cells, ensuring a faster recovery. Careful planning by the physician before the procedure, along with active cooling of the urethra and rectum during the procedure, protects the areas surrounding the prostate in order to prevent side effects.

What can TULSA-PRO treat?

TULSA-PRO treats two main conditions of the prostate:

TULSA-PRO is typically best suited for early-stage cancer patients. Once cancer grows beyond the wall of the prostate, traditional therapies—such as radiation or surgery—are typically more appropriate and effective.

What happens during a TULSA Procedure (TULSA-PRO)?

Patients receiving the TULSA Procedure will be placed in an MRI machine instead of a conventional operating table. The MRI gives the physician a clear image of the patient’s prostate to locate prostate cancer cells and irregularities in the prostate when treating BHP.

Using robotically controlled equipment, a thermal ultrasound device will be used in cooperation with the MRI to locate irregular prostate tissue which needs to be ablated (heat-treated) using very precise technology. The urologist will then mark the areas that need to be treated on the MRI. Using this as a guide, cancerous cells are ablated using the directional ultrasound probe. Once the ablation is completed, the patient can return home the same day with this minimally invasive procedure.

What are the steps to the TULSA Procedure to Treat Prostate Cancer & BPH?

After the patient is situated inside an MRI machine, the following steps are completed for the TULSA Procedure:

  1. Insertion of the ultrasound device: A directional ultrasound device is inserted through the urethra for later treatment of the prostate using high-intensity ultrasound waves.

  2. MRI scan to view the patient’s prostate: The MRI reveals the areas of irregular tissue, which informs the urologist of where they will be conducting the ablation using the ultrasound device.

  3. Marking the targets: The TULSA procedure is more specific because it uses an MRI during the procedure, whereas conventional surgery uses MRI’s before and after the surgery. By marking the targets to be ablated, only the cancer cells or irregular tissue is destroyed, preserving the natural function of the remaining prostate.

  4. Prostate Ablation: The ultrasound device next sends heated waves into the target areas to ablate them, thus destroying the prostate cancer cells or irregular prostate tissue.

What is HIFU Treatment (high-intensity focused ultrasound)?

HIFU is an alternative treatment option for prostate cancer that hasn’t spread beyond the prostate wall. Thus, it’s most appropriate for early-stage patients. HIFU stands for high-intensity focused ultrasound. These ultrasound waves heat up and ablate the targeted cancer cells, minimizing damage to the surrounding tissues and preserving as much normal functioning as possible.

Before a HIFU procedure, an MRI or ultrasound scan is usually performed to help guide the treatment. The scan provides information on the size and location of the cancerous tissue, allowing the healthcare provider to target the treatment more precisely. Patients will also receive specific instructions on how to prepare for the procedure, such as avoiding certain medications and fasting for a period of time beforehand.

What happens before a HIFU procedure?

Before the HIFU or TULSA procedures can be administered, an accurate diagnosis and prostate cancer staging must be performed to make sure this is the best prostate cancer treatment for you. Prostate Cancer is diagnosed using a combination of PSA bloodwork, a physical exam, a medical history of your prostate cancer symptoms, and an MRI Fusion Prostate Biopsy. Normally, an MRI or ultrasound scan is required to perform the HIFU procedure. The information can help the physician pinpoint exactly which tissue to target. Your provider will provide specific instruction on how to prepare for this procedure.

How effective is focal therapy for prostate cancer?

As of 2021, the Cleveland Clinic reported that the long-term effectiveness of focal therapy is still unknown. This is largely because focal therapy is so new; not enough time has elapsed to observe long-term effects. HIFU, for example, was FDA approved in 2015, and TULSA is even newer than that!

That said, studies are underway to monitor long-term efficacy of both treatment modalities, and initial, shorter-term results are promising.

What is the very latest treatment for prostate cancer?

The TULSA-Pro Focal Therapy procedure is the latest study currently underway for the treatment of prostate cancer. Called the CAPTAIN study, principal investigator, Dr. Kia Michel of Comprehensive Urology in Beverly Hills, CA, performed the first treatment of the new TULSA protocol for focal therapy. 

“This is a game changer,” Dr. Michel reported. “We just performed TULSA on the first patient in a clinical trial (called the CAPTAIN Study). Our hypothesis is that TULSA can deliver the same oncologic outcomes (cancer free states) as Robotic Surgery, but with less side-effects/better quality of life outcomes.”

How is prostate cancer  treated?

Conventional treatments for prostate cancer include surgery, prostatectomy (removing the entire prostate), and radiation therapy. These treatments are considered invasive forms of therapy that each have significant side-effects. Chemotherapy and hormone therapy can also be used in the treatment of prostate cancer.

More recently, minimally invasive focal therapy is being used, such as High intensity focused ultrasound HIFU and TULSA procedures. These options can be used to treat both BPH and prostate cancer.

In cancer treatment, many types of physicians work in concert to develop a plan of treatment that may combine many kinds of treatments to eliminate the cancerous cells. These are called multifaceted teams. Cancer care teams include other health professionals, including physicians, nurses, oncologists, and pharmacists.

Depending on a patient’s imaging and other test results, the cancer care team works together to identify which stage of cancer the patient is at, and which treatment(s) are most likely to be effective.

What are the symptoms of BPH vs Prostate Cancer?

The symptoms of BPH and prostate cancer can seem similar, as they both can impact your ability to urinate. If you’re experiencing any of the following symptoms, please visit a board-certified urologist to get an evaluation. Here’s a quick overview of the key symptoms typical of BPH and prostate cancer.

Symptoms of Prostate Cancer
  • Weak stream when urinating

  • Frequent need to urinate (more often than usual)

  • Blood in the urine or semen

  • Struggles to have and maintain erections

  • Pain in the hips, back, or torso

  • Weakness, tingling, or numbness in the legs or feet

  • Loss of bladder or bowel control

Symptoms of BPH

Symptoms of BPH can be similar to those of prostate cancer; however, symptoms of BPH tend to focus on problems with urination, such as:

  • Sudden urges to urinate

  • Urinating frequently (more often than usual)

  • A weak urine stream that only dribbles

  • A sensation that the bladder is not fully emptied after urinating

  • Straining to begin urinating

  • Difficulty having an erection or difficulty ejaculating

  • Blood in the urine

In order to be properly diagnosed for BPH, prostate cancer, or any other conditions that impact your ability to urinate, it’s essential to visit a board-certified urologist to conduct a full work-up. Many conditions can have the same symptoms, so the use of blood work, scans, and physical examinations can help determine the source of the problem.

How is prostate cancer normally treated?

There are several different treatment options for prostate cancer. Which treatment is utilized depends on the stage of the cancer, the patient’s age and overall health, and other factors. The most common treatment options for prostate cancer include surgery, radiation therapy, and active surveillance (also known as watchful waiting). Focal Therapies like HIFU and TULSA are additional treatment options best for early-stage patients.

Surgery for prostate cancer involves removing the prostate gland. Depending on the amount and location of cancer growth, sometimes nearby lymph nodes are also removed. This procedure is called a radical prostatectomy. It can be performed using open surgery—though more and more, it’s performed instead with minimally invasive techniques such as laparoscopy or robot-assisted surgery to reduce recovery time and risk of complications.

Radiation therapy uses high-energy radiation to kill cancer cells. It can be delivered externally—using a machine outside the body—or internally, using radioactive seeds placed in the prostate. This is called brachytherapy.

Active surveillance involves monitoring the cancer over time with regular check-ups, including prostate-specific antigen (PSA) blood tests and biopsies. Treatment is deferred unless the cancer shows signs of growing or becoming more aggressive.

In addition to these options, other treatments for prostate cancer include hormone therapy (also known as androgen deprivation therapy), chemotherapy, and immunotherapy. The choice of treatment depends on many factors and should be made in consultation with a healthcare provider who specializes in the treatment of prostate cancer.

What are Conventional Surgery Options for Prostate Cancer Treatment?

The most common type of surgery for prostate cancer is radical prostatectomy. This procedure involves removing the entire prostate gland and some surrounding tissue. There are different surgical techniques for performing radical prostatectomy, including:

  1. Open surgery: This is the traditional approach, where a large incision is made in the abdomen or between the anus and scrotum to access the prostate gland.

  2. Laparoscopic surgery: This is a minimally invasive procedure where several small incisions are made in the abdomen, and a laparoscope (a thin, lighted tube with a camera) and other surgical instruments are inserted to remove the prostate gland.

  3. Robot-assisted surgery: This is a type of laparoscopic surgery that uses a robotic system to perform the procedure. The surgeon controls the robotic arms to perform the surgery while seated at a console.

The choice of surgical approach depends on several factors, including the surgeon’s expertise, the patient’s overall health, and the stage of the cancer. Radical prostatectomy has a high success rate in treating prostate cancer when performed early and may be recommended for patients who have early-stage prostate cancer that has not spread beyond the prostate gland.

Side Effects of Surgery

As with any surgical procedure, side effects are a potential risk patients must consider as they work with their doctor to find the treatment that will be most effective. Infection is a risk inherent to even the smallest of surgical procedures. Additional side effects of radical prostatectomy for prostate cancer may include:

  1. Urinary incontinence: This is the inability to control urine flow. It can be temporary or permanent and can range from mild leakage to complete loss of bladder control.

  2. Erectile dysfunction: This is the inability to achieve or maintain an erection sufficient for sexual intercourse. It can also be temporary or permanent and can range from mild to severe.

  3. Bowel problems: Some patients may experience bowel problems such as diarrhea or fecal incontinence.

  4. Infertility: Radical prostatectomy can sometimes damage the nerves and structures responsible for producing semen, leading to infertility.

Not all patients will experience these side effects, and even if they do, the severity of side effects can vary depending on the patient’s age, overall health, and the extent of the cancer. In many cases, side effects can be managed with medications, lifestyle changes, or additional treatments such as penile rehabilitation therapy or pelvic floor exercises. It’s important to discuss the potential side effects of radical prostatectomy with a healthcare provider before deciding on this treatment option.

What New Clinical Trials for Prostate Cancer Treatments are currently being studied?

The National Cancer Institute, a division of the National Institutes of Health (NIH), lists several current ongoing studies for prostate cancer treatment. There are too many to list them all in this article—over 500 at the time of this writing!

For those interested in finding or participating in a study, the site has a search function allowing you to locate studies based on age, location, type of cancer, cancer stage, trial type and phase, and many more criteria.

Treating prostate cancer or BPH has become simpler and more effective with the TULSA-PRO system. This advanced treatment system uses thermal ablation to treat prostate disease while focusing on protecting functionality. Dr. Michel and his team are among the few groups in the world practicing this groundbreaking treatment.

At Comprehensive Urology in the Beverly Grove community of Los Angeles, we focus on improving our patients’ quality of life through advanced treatments. Kiarash Michel, MD, and his team use state-of-the-art imaging and diagnostic equipment to create a complete and accurate diagnosis for every patient. Using their expertise, they deliver a range of treatment options to effectively treat a range of prostate concerns. To schedule an appointment with the team, call Comprehensive Urology, or book a visit online now.

Kia Michel, MD

Kia Michel, MD

Written by Dr. Kia Michel, a board certified urologist, surgeon, and founding member of Comprehensive Urology in Beverly Hills, Los Angeles. Dr. Michel's expertise includes focal therapy (HIFU/TULSA), prostate cancer treatment, robotic surgery, and male enhancement treatments such as Shockwave Therapy for ED and penile injections.

Dr. Michel's Bio

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