On this episode of BackTable Urology, Dr. Aditya Bagrodia, Dr. Daniel Costa (UT Southwestern), and Dr. Xiaosong Meng (UT Southwestern) discuss patient selection and procedure for TULSA-PRO, a new transurethral ultrasound ablation system that incorporates real-time MR imaging, as a focal treatment option for prostate cancer.

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SHOW NOTES

First, the doctors discuss the benefits of using MRI with transurethral ultrasound ablation (TULSA), which include direct visualization of anatomy, margins, and boundaries. They compare TULSA to other forms of focal management, such as cryoablation, brachytherapy, stereotactic body radiation therapy (SBRT). Compared to these methods, TULSA has lower risk of rectourethral fissures and preserves the posterior plane better, making salvage procedures more viable.

Then, the doctors discuss ideal candidates for TULSA therapy, which include patients with intermediate risk and localized disease, patients with lesions in lateral or anterior portion of prostate, patients with medium sized prostates, low risk patients with lower urinary tract symptoms (LUTS) who do not want to undergo active surveillance. Patients with large calcifications may not be ideal candidates for TULSA, as the calcifications can be a shield for the ultrasound beam. The doctors recommend ordering a CT/MRI scan first to identify if calcifications are present to assess their sizes and locations. During imaging, it is also important to make sure the tumor is not close to key anatomical elements, such as the neurovascular bundle. When deciding between different focal therapies, it is important to balance oncological outcomes and quality of life preservation. Thus, the treatment decision should be a collaboration between patients, their families, the radiologist, and the urologist. The doctors also discuss special considerations for salvage therapy patients, brachytherapy patients, patient with urethral strictures, and patients with a prior history of TURP.

Next, the doctors explain how to prepare patients for TULSA. The patient’s colon has to be emptied in order to reduce MRI noise during the procedure. Additionally, the doctors help patients understand the immediate side effects of the procedure, which can include reduced semen volume, urgency incontinence from bladder and prostate irritation, and temporary erectile dysfunction, and semen retention. After the procedure, the urinary catheter will have to be left inside for five days to two weeks, depending on the volume of the prostate removed. There is a 20-25% chance of recurrence.

Finally, they discuss specifics of the TULSA procedure. Dr. Costa and Dr. Meng perform these procedures at the university hospital, as they need access to MRI and anesthesia. They discuss the optimal MRI window for the procedure, patient positioning, as well as their two sweep method. The total procedure time is dependent on the volume of ablation and number of sweeps, but the average total time is 3 hours. Patients are discharged on the same day, and no narcotics are prescribed. Finally, they discuss the progress of a new prospective multi-center randomized trial comparing focal TULSA therapy to surgery for intermediate risk prostate cancer patients.

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RESOURCES

TULSA Procedure

https://tulsaprocedure.com/tulsa-procedure/about-tulsa-procedure/

Profound Medical

https://profoundmedical.com/

Ep. 94 TULSA Pro: A Practical Guide for Setup and Success with Dr. Xiaosong Meng and Dr. Daniel Costa