From Focal Therapy to Radical Prostatectomy, Andy's Prostate Blog Extra Details, Professor Caroline Moore, Prostate Cancer Focal HIFU Therapies Cryotherapy UCLH Manit Arya Mark Emberton London UK

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Andy's Prostate Blog Details
2014-2020

Some more details that may be of concern to men with, or suspecting they have, early-stage prostate cancer.

This page contains a summary of my experience, plus some more intimate and explicit details.

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Focal therapies, definition: these try to focus on the significant cancer area only, as opposed to a radical prostatectomy. In the latter case, the whole porstate is removed, which can lead to more serious after-effects than focal therapy.

The limitations of HIFU (or perhaps ANY method) as a focal therapy

Since making my choice to have HIFU about 2 weeks ago, I've had second thoughts.

It appears that HIFU, despite being described as a “focal” therapy, is limited as to how small an area it can treat, if the tumour is not close to the posterior (rectum) side. This applies in my case, because my tumour is an anterior tumour, which means HIFU must reach right across the width of my prostate to get the energy to it, and, to do that, may destroy some good tissue on the way.

My tumour is less than 1cc of my total 28cc prostate volume, i.e., less than 5%. I am thankful to God for directing me, using my GP and Emberton's team, to find out about it before it became a bigger and more serious tumour.

The consultants at UCLH originally suggested Cryotherapy as a suitable treatment. However, I initially chose HIFU because I liked the idea of some treatment it would also do to my peripheral (posterior) 3+3 gleason area.

HIFU is shown being used at UCLH on one of 2 prostate patients in a "Curing Cancer" documentary on Channel 4, towards the end of the documentary. The other prostate patient tests as not having cancer. See the links section.

However, because of the reasons mentioned above re. a large area of my prostate being affected, I've now chosen Cryotherapy treatment instead. (I like to call it "the Brass Monkey Treatment"!)

Emberton also agreed that treating the anterior tumour alone, would improve my chances of preserving erections.

The manufacturer's video below gives a vague idea of how Cryo treatment works. This "Galil" kit is what UCLH use.

Note: Cryo gives very similar results to Nano Knife: they are both focal therapies.

[November 2014]: I've recently learnt that the medical term for these sort of therapies is "interventional oncology". There, now you (and I) know!

The above video appears to show whole gland therapy, rather than the focal therapy I'll have. Emberton says I should end up with only about 5cc of my prostate ablated, which sounds "pretty good", should leave around 23cc of my 28cc prostate! Unless, I can come up with a more precise therapy!

For a reasonably detailed article on Cryo by Fuda Hospital, click here

For the UCLH patient info for Cryotherapy, click here

I had the cryo surgery on April 22nd 2014. To read how it went, - click here

"Dry Climax" Side effect.

Only recently noticed reference this in one of the UCLH Patient information sheets. It says: "50% chance of the side effect of dry climax".
I emailed Emberton about this, "Did it also apply to focal treatement?" and he said: "It is very hard to predict hence the high rate. I think it is a reasonable estimate given the uncertainty. In most prostate procedures it is 100%. "

So, my question for the sugical team before my Cryo next week will be: "Could this be a temproary side-effect, or permanent?" I suspect the answer will be: "Could be either".

I had the opportunity to ask Manit's consultant about it on April 1st. That was the original date for my Cryo, but it was cancelled because another (probably much less fortunate) patient before had complications in theatre. He told me: "Yes, it's 50:50. It's because semen may no longer be prevented from going into the bladder. You've heard of the "TURPS" procedure? Well, with that, the dry climax side effect is always 100%." Update: see bottom of "Surgery experience" section below.

My recovery

Well, some of my side-effects have been already mentioned in both the surgery and catheter sections.
More of my recovery details will be posted in this section.

[5th May 2014] My first, is my experience of trying to gradually increase my exercise.

Having been told not to cycle for a month, I decided to try what I considered to be “gentle” exercise over this weekend.

I walked 2 stints of about ¾ mile on Saturday. Result: felt ok. So, decided to walk all the way to our church Sunday morning – about 2.5 miles.

Result: felt rather tired. Kind-of expected that, so got a lift home from a friend.

However, started to feel exhausted during the afternoon. Also, noticed a small amount of blood in my urine, suggesting that slight internal bleeding may have occurred (not had that for about a week, otherwise I’d have assumed it to be a normal side-effect).

The surgeon did mention that straining is one key thing to avoid: "straining is an increase of your intra-abdominal pressure as when lifting".

So I’ve learnt by experience that, whilst walking isn’t so strenuous an exercise as cycling, I still need to take it easy in that department.

Just as well I have a bus service that passes my door!

Next test: Prostate MRI on 10th May. Hospital agreed to prescribe me Diazepam for that, because I found the MRI I had last year (for my original diagnosis at Nuada Medical Imaging centre) rather claustrophobic. That may have been because that was an older machine than they'll use for me at UCLH, which is relatively new. Maybe that's an advantage of having an MRI on the NHS at UCLH, rather than privately at Nuada Medical. I'll let you know what I thought, after my MRI on 10th May.

[6th May]: Waited about 90 minutes at the UCLH Parmacey, and received.......one Temazepam 10mg! (Kind-of a mild Valium pill). Could certainly help me suffer less stress from claustrophobia during the MRI, although the surgeon suggests that the imaging folks may get a little uneasy about my taking it. Oh well, I'll see how things go on the 10th.

Why was I told not to cycle for a month? Well, in the Cryo Patient Info Sheet, I read in section 12, (page 12), "For the first 6 weeks after cryotherapy you should not lift anything heavier than a full kettle.". So, I emailed the surgeon, and he translated that into the recommendations I've written above. Actually: not to cycle the 9.5 miles to work for 6 weeks, and not to cycle the 3.5 miles from London Bridge station for 4 weeks.

[7th May] Been back at work 2 days. Coping quite well - my job is electronic repairs, so it's light work - kind-of like repairing mobile phones (but the very old "brick" type!)
But I'm avoiding lifting heavy boxes containing 40 of those units.

Have to admit to mildly panicking on Tuesday (my first day back), worried I might suffer ill-effects from the exertion of the journey (on public transport), and then at work itself. But I didn't, so I'm thankful for that.

Still find it painfull pee-ing, but have emailed the surgeon about that. [16th May]: has certainly improved now.

[16th May]: Also, as the surgeon said a week ago, slight blood in urine has more-or-less ceased.

[22nd May]: Very pleased to report that my continence and erectile and ejaculatory functions all appear to be unaffected, except if I try to hold myself to "busting for the loo", when I find I might leak slighty, something that I could control ok before. See the consultation for comment on this.

See the consultation also for other recovery updates.

[30 May]: Tried cyling for the first time since my surgery (nearly 6 weeks!). Felt really good, again to have the fresh air on my face, and breath it more deeply than when I'm merely walking.

Intending now to take the folding bike on the train, and try cycling to work the 2 miles from London Bridge station to the office, untill I feel up to cycling the full 9.5 miles all the way to work.

[13 June 2014]: for the last 3 days, been doing my full commute (9.5 miles) on my full-size bike (It went in for a re-build during the same time I had my surgery! I wore it out with around 20,000 miles commuting!). I was fed up with squeezing on and off trains with my folding bike! This is despite the surgeon suggesting it should be next week that I start. So, am I irresponsible? I don't think so, for the following reason:

I was very fit before my surgery, so probably I had recovered a bit quicker than I otherwise would have.

I should mention that I'm not fully back up to the fitness I had before: find myself having to change into lower gears sooner, but doesn't affect my commute time noticeably. And, thankfully: such great summer weather to "welcome" me back to my commute to work in the city!

[17th June 2014]: Now seem to be back to my former fitness level. Cycling in the same gears I used to.

[19th July 2014]: Ejaculation volume, and "dry climax" symptom.
Initially, soon after my surgery, my ejaculation volume appeared similar to my pre-op volume.
However, now, nearly 3 months on, it seems to have diminished to a few drips.
Difficult to say if this is reduced seminal fluid production, or my ejaculate going into my bladder.
My impression is the former, since I am not seeing any cloudy effect in my urine after ejaculation, as should be the case if my ejaculate were "going the wrong way" into my bladder.

Although it's difficult to determine: my volume of premature seminal fluid ("pre-cum") apperas similar to my pre-op amount, so maybe it is the fact that I'm simply not ejaculating like I used to.

Will be interested to see the result of my next MRI that I'll have in November.

Update May 2019:
10 days after my HIFU.
Erections still GOOD.
Ejaculation: NONE during orgasm. And a bare hint (smear) on penis glans about 10 minutes afterwards.

Update July 2016: Sometimes it seems I manage some ejaculation after normal masturbation. But not as much as previously. However, after visual sexual stimulation in additon, I often find I manage more ejaculation. But difficult to say if this is as much as before my operation.

[22 August 2014]: Ejaculation now down to nothing. This is then followed by slight oozing.

Asked Emberton by email, (My erections are still normal).

His reply:"Ejaculation is always diminished after focal treatment - it goes
completely in all the other therapies.

About 50% of men manage to preserve some ejacualtion but this depends on
what needs treating.

It will not return. All men are warned of this.

You are probably ejaculating but it is expelled backward into the bladder.
[my observation: this is also known as the "dry climax" effect]

It does not affect the climax or orgasm."

My questinon: "Why did ejaculation diminish steadily over about 4 months, rather than straight away, after the cryo?"

His answer: "Hard to know exactly. This is the time over which the contraction of the scarring and therefore contraction occurs. That is probably the dominant reason."

Update: about 6 months after writing the above, ejaculation increased to a small amount. Observation over the following years shows it remained at that level, until my HIFU in May 2019. Click here for more info on that.

Based on that last comment, it will be interesting to see if the ablated area has shrunk, on my next MRI scan, which is booked for 17th November 2014, follow-up consultation with Emberton on 10th December 2014.

Updates extra details (some explicit) - most recent listed first

Contact me

My consultation of 4th December 2019 with Prof Caroline Moore (she's the surgeon who performed my HIFU on 14th May 2019).

It was a pleasure to see Andrew in clinic today. He had cryo therapy for right-sided prostate cancer in 2014 and then had HIFU to the left side of his prostate in May 2019. There was Gleason 3+4 disease in anterior and posterior lesions on the left and both of these were treated at the same time.

His PSA has hardly changed from his pre-treatment PSA 5.99. His most recent value was 5.3 in September.

His MRI scan from November 2019 has shown some enhancement on the right side of the prostate. I think it is prudent to do a biopsy of this and of the residual left prostate. As a precaution I have also requested a PSA and a PET scan as I would like to be clear on whether or not there is any disease outside of the prostate.

Andrew will receive an appointment for the biopsy and a PET scan and we look forward to catching up in clinic for the results.

Very best wishes

Professor Caroline Moore MD FRCS (Urol)
Head of Urology University College London
Honorary Consultant Urologist UCLH

Showing the enhancement on image from my November 2019 MRI

My consultation of 10 July 2019 with Dr Thomas Collins (he's the surgeon who performed my Template Biopsy on 22nd February).
His letter to my GP (summarised):

"I met Mr. A........... on 10/7/2019. He attended for a review having had a high-intensity focused ultrasound treatment to the left side of his prostate for prostate cancer in May here at UCH. I am pleased to hear his doing well having had his catheter removed describing no significant change in his urinary symptoms and no incontinence. He describes good erectile function 2 months after the treatment. He has had a PSA which came back at 5.9 which is slightly higher than his pre-treatment level however I think this is not surprising given the proximity to his treatment and I would suggest waiting another 2 or 3 months before repeating this. I will expected to fall below 3 if we repeat it in September.

I have routinely requested an MRI scan from May of next year and I would be most grateful if you could continue to monitor his PSA 3 monthly. He has a contact details for the team to get in touch if he has any concern. "

My additional observation to date (19th July 2019):
A couple of weeks after my HIFU treatment, my ejaculations were dry, except for a small amount about 10 minutes later.

However, in the last few weeks, my ejaculation has returned to my pre-HIFU amount, which is not much - enough to wet the outside of my penis.

It may reduce again, I don't know. It's probably an idicator that my prostate is still settling down after the HIFU.

(Early August 2019) - this may have been a one-off; ejaculation is now back to zero except for a little appearing about 10 minutes later.

This is now as was predicted before my HIFU "ejaculation will probably be zero"

Found this page helpful? Want to share your experience with me?

Hopefully, I'll be updating you with how I get on over the coming months and years!

Useful Links

To see the Webcast where Prof Emberton answers patients questions, click here.

NanoKnife is mentioned in the video at the 19 minutes slider position.

Prostate anatomy drawings:

click here

For the Nano Knife trials info sheet,

Please note: as of August 2014, these Nano trials at UCLH have finished, but the study continues.

click here

For more info on the UCLH Cancer Centre,

NOTE:this is NOT the address for initial consultatins. Please see below for that.

click here

For more about HIFU,

click here

For the ORCHID "fighting male cancer" website,

click here

For Mark Emberton and Caroline Moore's NHS details at UCLH,
(See also below)

click here.

For the Pelican Cancer Foundation,

click here

My discussions on the Prostate Cancer UK site

click here

For the "HealingWell" forum site,

click here

For London Cancer website,

click here

For the UCLH patient info sheet for Cryotherapy,

click here

The NHS UCLH Urology referral address is:

You need to be referred by your GP. Under the Patient Choice option, you can ask to be referred there even if you do not live in the central London Area.

This is your right, click here
to see my referral letter.

Click here

Nisma Akhtar is PA for Emberton and his team:
Telephone 020 3447 9194
or 020 3447 9485 (main dept)

Emberton and Caroline Moore's Private West End referral address - click on the link on the right

Click here

Note: if you're thinking of having private treatment under Emberton, check that your insurance covers the imaging place and the hospital that Emberton uses.
I opted out of private treatment after my TPM Biopsy, and had my final cryo done on the NHS, as I explain above.

Also, for a private consultation with Emberton, you don't have to be referred by your GP (as you do for NHS UCLH).
If you are self-funding, you can simply go along and refer yourself.
Otherwise, check with your insurance first.

Press articles

Different!

Shows the advantage of early diagnosis. This man had no symptoms of Prostate Cancer

Mr Bartram said he [only] discovered he had early-stage cancer when he visited a doctor about his injuries.

See Royal couturier David Emanuel's Mail online article
"Andrew Lloyd Webber's honesty about prostate cancer saved my life"

Note: thankfully, because my cancer was diagnosed early, I didn't need my prostate removed.

Read about the late Bob Monkhouse campaign

Not sure how to interpret this BBC article! Perhaps it reflects the fact that many men still aren't benefitting from the greater accuracy of the MRI & TPM Biopsy test, or that even that can't predict how aggressive the cancer is.
I admit that it appears uncertain how quickly my anterior tumour would grow, if it were left alone. But see consultation above.
Pity it doesn't even mention focal therapy!

BBC Health:
Prostate cancer tests miss severity in half of cases

Got any comments? Contact me using the button on the right:

Focal therapy is an amazing treatment.
However, it can still only cure my body until it will die anyway.
But praise God: I'm assured of eternal life because I believe in the atoning work done by Jesus Christ, when he died for my sin, and rose again!
You too can have this same eternal assurance, if you believe!

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