High Intensity Focused Ultrasound (HIFU)

High Intensity Focused Ultrasound

HIFU, high intensity focused ultrasound, is a non-invasive treatment for prostate cancer. Following FDA approval of Sonablate® in 2015, Indiana University School of Medicine Department of Urology faculty physicians became among the first to acquire the system to provide HIFU to patients as a focal treatment for prostate cancer. This device allows precise application of heat to destroy cancer tissue with low risk of side effects such as erectile dysfunction and urinary control issues. HIFU is radiation-free and does not require incisions.


A probe is placed in the rectum for treatment, and high-energy ultrasound waves are focused on the prostate. The device contains an ultrasound for imaging to select regions for treatment and to monitor the effects of treatment in real-time. Sound waves are focused to heat tissue to nearly 200F, but the intervening tissue, including the rectum, is not heated. The process is analogous to using a magnifying glass to focus sunlight and heat an area.

A cooling system circulates chilled water throughout the procedure to prevent rectal heating and injury.

HIFU provides reliable cancer destruction in the targeted area without radiation or incisions, and the treatment has limited side effects, offering low risk of incontinence and erectile dysfunction. This treatment is an outpatient surgery procedure (2-4hours) with a short recovery.

Patients with early-stage prostate cancer that has not spread beyond the prostate are the best candidates for HIFU treatment. Prostate cancer that is localized to one side of the prostate on biopsy and MRI allows for focal treatment with fewer side effects. The treatment shows best results on small to medium-size prostate glands (height less than 4cm and volume <50cm3) and in patients who have excellent erectile and urinary function.

Cancer grade or Gleason score, as it’s called, is determined from the prostate biopsy. Gleason grades are grouped into three risk levels: 6 (low), 7 (intermediate), 8-10 (high).

Cancer stage (clinical) is defined as:

  • Discovered incidentally by PSA or by BPH surgery.
  • Palpated on digital rectal exam and felt to be contained in the prostate.
  • Palpated on digital rectal exam and felt to be extending through the prostate capsule.
  • The tumor is invading local structures such as pelvic side wall.

Traditionally, the rectal exam, PSA blood test and prostate biopsy Gleason grade were used to predict the risk of cancer spreading beyond the prostate. However, some cancers extending beyond the prostate can be missed by these tests alone. Now, 3-Tesla multi-parametric MRI scans are used to better locate cancer and predict if it has spread outside the prostate.

HIFU is limited to treating cancer within the gland and cannot treat cancer spreading beyond the gland or into lymph nodes. In some cases, the surgical removal of the prostate and lymph nodes (e.g. robotic prostatectomy) can remove prostate cancer that has spread beyond the prostate.

The PSA test is checked periodically followed treatment with HIFU or prostate removal. After HIFU, it should decrease significantly and remain stable with only slow rises over the rest of a patient’s life. A repeat biopsy is performed six months after HIFU to look for persistent cancer. After surgical removal of the prostate, the PSA should be undetectable. Prostate cancer that has spread outside the prostate (metastasized) is typically slow-moving and requires many years to cause symptoms and death. Due to this, if your life expectancy is less than 10 years, you might receive more harm than benefit from treatment.

Yes, in some cases an additional HIFU treatment can be given. Surgery and radiation can be used after HIFU as well.

HIFU was recently approved by the FDA and is not yet covered by insurance companies.

To learn more about HIFU or make an appointment with an IU School of Medicine faculty expert, visit the prostate cancer page on the IU Health website.

Faculty Experts

Michael O. Koch, MD

Michael O. Koch, MD

Chair, Department of Urology
Clint D. Bahler, MD,  MS

Clint D. Bahler, MD, MS

Assistant Professor of Urology