Transurethral Ultrasound Ablation Research Articles

MR-Guided Transurethral Ultrasound Ablation (TULSA)-An Emerging Minimally Invasive Treatment Option for Localised Prostate Cancer.

The optimal treatment strategy for men with localised prostatic cancer of low and intermediate risk is an actively evolving field. It is important to strike a balance between maximal oncological control and minimal treatment-related complications, which helps preserve the patients' quality of life. MR-guided transurethral ultrasound ablation (TULSA) has emerged as a minimally invasive treatment option for this group of patients. This article aims to provide of a background on TULSA technology, a step-by-step procedural guide of MR-guided TULSA and to summarise the current evidence of TULSA in management of localised prostatic cancer, as well as other potential indications.

Minimally invasive techniques in quest of Holy Grail of surgical management of enlarged prostates: a narrative review.

Past decade has seen a renewed interest in minimally invasive surgical techniques (MISTs) for management of enlarged prostate. This narrative review aims to explore newer MIST for benign prostatic hyperplasia (BPH) which are not yet integrated into established societal guidelines. We conducted a literature search across PubMed, Google Scholar, and FDA ClinicalTrials.gov databases on June 1st, 2023, to identify studies published within the past decade exploring various MISTs for BPH. Additionally, we gathered insights from abstracts presented in meetings of professional associations and corporate websites. We broadly classified these procedures into three distinct categories: energy-based, balloon dilation, and implant/stent treatments. We collected detail information about the device, procedure details, its inclusion and exclusion criteria, and outcome. Our review reveals that newer energy-based MISTs include Transperineal Laser Ablation, Transurethral Ultrasound Ablation, and High-Intensity Focused Ultrasound. In the sphere of balloon dilation, Transurethral Columnar Balloon Dilation and the Optilume BPH Catheter System were gaining momentum. The noteworthy implants/stents that are on horizon include Butterfly Prostatic Retraction Device, Urocross Expander System, Zenflow Spring System, and ProVee Urethral Expander System. The exploration of various MISTs reflects ongoing efforts to enhance patient care and address limitations of existing treatments. This review provides a bird-eye view and valuable insights for urologists and researchers seeking to navigate the dynamic landscape of MISTs in the quest for effective and minimally invasive solutions for enlarged prostates.

Salvage Radical Prostatectomy for Recurrent Prostate Cancer: A Systematic Review (French ccAFU).

The aim of this study was to systematically review the current evidence regarding the oncological and functional outcomes of salvage radical prostatectomy (sRP) for recurrent prostate cancer. A systematic review was conducted throughout September 2022 using the PubMed, Science Direct, Scopus, and Embase databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. A total of 55 studies (3836 patients) met our eligibility criteria. The vast majority of men included had radiation therapy (including brachytherapy) as their first-line treatment (n = 3240, 84%). Other first-line treatments included HIFU (n = 338, 9%), electroporation (n = 59, 2%), proton beam therapy (n = 54, 1.5%), cryotherapy (n = 34, 1%), focal vascular targeted photodynamic therapy (n = 22, 0.6%), and transurethral ultrasound ablation (n = 19, 0.5%). Median preoperative PSA, at the time of recurrence, ranged from 1.5 to 14.4 ng/mL. The surgical approach was open in 2300 (60%) cases, robotic in 1465 (38%) cases, and laparoscopic in 71 (2%) cases. Since 2019, there has been a clear increase in robotic versus conventional surgery (1245 versus 525 cases, respectively). The median operative time and blood loss ranged from 80 to 297 min and 75 to 914 mL, respectively. Concomitant lymph node dissection was performed in 2587 cases (79%). The overall complication rate was 34%, with a majority of Clavien grade I or II complications. Clavien ≥ 3 complications ranged from 0 to 64%. Positive surgical margins were noted in 792 cases (32%). The median follow-up ranged from 4.6 to 94 months. Biochemical recurrence after sRP ranged from 8% to 51.5% at 12 months, from 0% to 66% at 22 months, and from 48% to 59% at 60 months. The specific and overall survival rates ranged from 13.4 to 98% and 62 to 100% at 5 years, respectively. Urinary continence was maintained in 52.1% of cases. sRP demonstrated acceptable oncological outcomes. These results, after sRP, are influenced by several factors, and above all by pre-treatment assessment, including imaging, with the development of mpMRI and metabolic imaging. Our results demonstrated that SRP can be considered a suitable treatment option for selected patients, but the level of evidence remains low.

Optimal Strategies for Managing Prostate-specific Antigen Recurrence After Primary Radiotherapy in Prostate Cancer: The Finnish Perspective

Biochemical recurrence after radiotherapy for prostate cancer is a clinical dilemma. Patients at low risk of disease progression can be safely monitored. In Finland, options for those with reasonable life expectancy include salvage high-dose-rate brachytherapy and transurethral ultrasound ablation under magnetic resonance imaging guidance.

First experiences using transurethral ultrasound ablation (TULSA) as a promising focal approach to treat localized prostate cancer: a monocentric study

PurposeTo share our experience using transurethral ultrasound ablation (TULSA) treatment for focal therapy of localized prostate cancer (PCa).Materials and methodsBetween 10/2019 and 06/2021 TULSA treatment for localized PCa was performed in 22 men (mean age: 67 ± 7 years, mean initial PSA: 6.8 ± 2.1 ng/ml, ISUP 1 in n = 6, ISUP 2 in n = 14 and 2 patients with recurrence after previous radiotherapy). Patients were selected by an interdisciplinary team, taking clinical parameters, histopathology from targeted or systematic biopsies, mpMRI and patients preferences into consideration. Patients were thoroughly informed about alternative treatment options and that TULSA is an individual treatment approach. High-intensity ultrasound was applied using an ablation device placed in the prostatic urethra. Heat-development within the prostatic tissue was monitored using MR-thermometry. Challenges during the ablation procedure and follow-up of oncologic and functional outcome of at least 12 months after TULSA treatment were documented.ResultsNo major adverse events were documented. In the 12 month follow-up period, no significant changes of urinary continence, irritative/obstructive voiding symptoms, bowel irritation or hormonal symptoms were reported according to the Expanded Prostate Cancer Index Composite (EPIC) score. Erectile function was significantly impaired 3–6 months (p < 0.01) and 9–12 months (p < 0.05) after TULSA. PSA values significantly decreased after therapy (2.1 ± 1.8 vs. 6.8 ± 2.1 ng/ml, p < 0.001). PCa recurrence rate was 23% (5/22 patients).ConclusionEstablishment of TULSA in clinical routine was unproblematic, short-term outcome seems to be encouraging. The risk of erectile function impairment requires elaborate information of the patient.

Evolution of non-perfused volume after transurethral ultrasound ablation of prostate: A retrospective 12-month analysis

BackgroundA detailed understanding of the non-perfused volume (NPV) evolution after prostate ablation therapy is lacking. The impact of different diseased prostate tissues on NPV evolution post-ablation is unknown. PurposeTo characterize the NPV evolution for three treatment groups undergoing heat-based prostate ablation therapy, including benign prostatic hyperplasia (BPH), primary prostate cancer (PCa), and radiorecurrent PCa. Materials and methodsStudy design and data analysis were performed retrospectively. All patients received MRI-guided transurethral ultrasound ablation (TULSA). 21 BPH, 28 radiorecurrent PCa and 40 primary PCa patients were included. Using the T1-weighted contrast-enhanced MR image, the NPV was manually contoured by an experienced radiologist. All patients received an MRI immediately following the ablation. Follow-up included MRI at 3- and 12 months for BPH and radiorecurrent PCa patients and at 6- and 12 months for primary PCa patients. ResultsA significant difference between BPH and radiorecurrent PCa patients was observed at three months (p < 0.0001, Wilcoxon rank sum test), with the median NPV decreasing by 77 % for BPH patients but increasing by 4 % for radiorecurrent PCa patients. At six months, the median NPV decreased by 97 % for primary PCa. Across all groups, although 40 % of patients had residual NPV at 12 months, it tended to be < 1 mL. ConclusionThe resolution of necrotic tissue after ablation was markedly slower for irradiated than treatment-naïve prostate tissue. These results may account for the increased toxicity observed after radiorecurrent salvage therapy. By 12 months, most necrotic prostate tissue had disappeared in every treatment group.

Durability of Functional Outcomes After MRI-Guided Transurethral Ultrasound Ablation of the Prostate

Long-term data on functional outcomes after MRI-guided transurethral ultrasound ablation (TULSA) are limited. We assess the 5-year post-TULSA durability of outcomes for patient-reported genitourinary function, bowel function, and adverse events in 30 patients with primary, localized prostate cancer treated with TULSA across 3 centers. Patients received a conservative treatment plan in a phase 1 study designed to assess safety and feasibility. Follow-up visits took place at 1, 3, 6, 12 months, and biannually up to 5 years. Median (interquartile range) age at baseline was 69 (67-71) years. Erectile dysfunction (International Index of Erectile Function [IIEF] ≤17) was prevalent at baseline, with a mean (95% confidence interval [CI]) score of 16 (12-19), decreasing to 9 (4-14) at 5 years. At the 5-year visit, 71% of men who attempted intercourse in the recall period reported preservation of IIEF Q2 ≥2 erections sufficient for penetration. The mean (95% CI) International Prostate Symptom Score (IPSS) decreased from 9.0 (7.0-11) to 7.1 (5.0-9.1) from baseline to 5 years; IPSS-quality of life, maximum urinary flow rate, and post-void residual urine were stable or improved. Maintenance of bowel function and urinary continence was 100%. There was no new attributable serious or severe adverse event from 1 to 5 years. With a durably favorable safety profile, TULSA has the potential to treat cancer conservatively while simultaneously alleviating lower urinary tract symptoms. Data from larger studies are pending.

MR-Guided Transurethral Ultrasound Ablation of Prostate Cancer: Initial Experience of Monitoring Tumor Response by Dynamic Apparent Diffusion Coefficient Measurements at 3.0 T

Introduction: Diffusion-weighted imaging (DWI) as part of multiparametric magnetic resonance imaging (mpMRI) is an important sequence for the detection of prostate cancer (PCa). The objective of this retrospective analysis was to evaluate changes in apparent diffusion coefficient (ADC) measurements in biopsy-proven PCa undergoing TULSA-PRO (MR-guided transurethral ultrasound ablation of the prostate) at 3.0 T after 1, 3, and 6–12 months posttreatment. Methods: Nineteen patients underwent follow-up examinations after 1, 3, and 6–12 months including mpMRI at 3.0 T and urological-clinical examinations with quantitative analysis of ADCs. Results: In PCa, a significant increase of ADC values after 6–12 months was measured after TULSA-PRO treatment by 29.1% (pre-TULSA: 0.79 ± 0.16 × 10−3 mm2/s, 6–12 months: 1.02 ± 0.35 × 10−3 mm2/s), while the corresponding value in the reference tissue decreased by 48.5% (pre-TULSA: 1.20 ± 0.15 × 10−3 mm2/s, 6–12 months: 0.91 ± 0.29 × 10−3 mm2/s). The mean ADC values in the early follow-up groups at 1 and 3 months did not change significantly. Conclusion: DWI with ADC as part of mpMRI can serve as a biomarker to dynamically monitor the follow-up after TULSA after 6–12 months. For early posttreatment progression, it is not suitable due to too many confounding variables.

MP73-09 A RETROSPECTIVE CLINICAL SERVICE EVALUATION OF LESION-TARGETED MRI-GUIDED TRANSURETHRAL ULTRASOUND ABLATION (TULSA) FOR THE TREATMENT OF LOCALIZED PROSTATE CANCER

You have accessJournal of UrologyCME1 Apr 2023MP73-09 A RETROSPECTIVE CLINICAL SERVICE EVALUATION OF LESION-TARGETED MRI-GUIDED TRANSURETHRAL ULTRASOUND ABLATION (TULSA) FOR THE TREATMENT OF LOCALIZED PROSTATE CANCER Rolf Muschter, Leonhard Steinmeister, and Agron Lumiani Rolf MuschterRolf Muschter More articles by this author , Leonhard SteinmeisterLeonhard Steinmeister More articles by this author , and Agron LumianiAgron Lumiani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003341.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MR-guided transurethral ultrasound ablation (TULSA) is a novel minimally-invasive therapy option for the treatment of organ-confined prostate cancer (PCa) through a whole-gland or lesion-targeted approach. TULSA has shown promising safety and oncological outcomes with minimum side-effect on patients urinary, bowel, and sexual functions. The objective of this retrospective single-center study was to perform a clinical service evaluation of lesion-targeted TULSA for patients with localized PCa. METHODS: Men with organ-confined PCa (proved by MRI and biopsy) received lesion-targeted TULSA with sparing of sphincter, urethra, and rectum. A customized treatment was planned for every patient based on his expectations and PCa characteristics. For a subset of men with concurrent PCa and benign prostate hyperplasia (BPH), TULSA was applied as a combined therapy. Repeat TULSA was allowed and a suprapubic catheter was used. The Clavien-Dindo stratification was used to assess the frequency and severity of all adverse events (AEs). Mid-term oncological outcomes were evaluated using multi-parametric MRI (mpMRI) and prostate-specific antigen (PSA). Surgeon-assessed functional outcomes were recorded. RESULTS: 180 patients (150 primary and 30 salvage) with median [IQR] age, baseline PSA, and follow-up availability of 67 [63-76], 8.0 ng/ml [5.2-13], and 12-mon (max 48), respectively, were treated. 40 patients experienced Grade 1 and 2 AEs, resolving within 4 weeks using antibiotics or relevant medication. Grade 3 AEs (urinary retention requiring surgical intervention) occurred in two patients, resolving within 3 months. No grade 4 or higher events and no bowel-related complications occurred. 98% of men preserved pad-free continence. 94/94 men, who were previously potent, maintained erectile potency. 85% of men with concurrent BPH and PCa experienced symptom relief. The mid-term oncological success rate was 88%. A single repeat TULSA was performed on 13 patients. CONCLUSIONS: Lesion-targeted TULSA is a safe and customizable prostate ablation therapy with promising mid-term oncological outcomes and minimal side-effect profile on patients erectile, bowel, and urinary functions. TULSA offers the flexibility to treat localized prostate cancer in a primary, salvage, or concurrent setting of BPH through a patient-tailored whole-gland or lesion-targeted approach. Source of Funding: No funding was received © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1038 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rolf Muschter More articles by this author Leonhard Steinmeister More articles by this author Agron Lumiani More articles by this author Expand All Advertisement PDF downloadLoading ...

MP76-10 TRANSURETHRAL ULTRASOUND ABLATION (TULSA) FOR BENIGN PROSTATIC OBSTRUCTION: 12 MONTHS CLINICAL OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP76-10 TRANSURETHRAL ULTRASOUND ABLATION (TULSA) FOR BENIGN PROSTATIC OBSTRUCTION: 12 MONTHS CLINICAL OUTCOMES Mikael Anttinen, Antti Viitala, Pouya Doerwald, Pietari Mäkelä, Pertti Nurminen, Heikki Pärssinen, Teija Sainio, Ilari Virtanen, Pekka Taimen, Roberto Sequeiros Blanco, and Peter J. Boström Mikael AnttinenMikael Anttinen More articles by this author , Antti ViitalaAntti Viitala More articles by this author , Pouya DoerwaldPouya Doerwald More articles by this author , Pietari MäkeläPietari Mäkelä More articles by this author , Pertti NurminenPertti Nurminen More articles by this author , Heikki PärssinenHeikki Pärssinen More articles by this author , Teija SainioTeija Sainio More articles by this author , Ilari VirtanenIlari Virtanen More articles by this author , Pekka TaimenPekka Taimen More articles by this author , Roberto Sequeiros BlancoRoberto Sequeiros Blanco More articles by this author , and Peter J. BoströmPeter J. Boström More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003350.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: MRI-guided transurethral ultrasound ablation (TULSA) is a novel therapy option for treating lower urinary tract symptoms (LUTS) caused by benign prostatic obstruction (BPO). The combined data set of all 27 patients is reported here with 12-month outcomes available for 21 men. METHODS: Men with LUTS due to BPO, previously scheduled for primary TURP, were enrolled in this prospective, investigator-initiated, single-center, phase 1-2 study (NCT03350529). Quality of life (QoL) questionnaires including EPIC-26, IPSS , IIEF-5 as well as uroflowmetry and PSA were recorded at baseline, 3, 6, 9, 12, 18, 24, and 36 months post-TULSA. MRI was obtained at baseline, 3- and 12-months. Medication use before and after TULSA and adverse events (AEs) in Clavien-Dindo classification were recorded. RESULTS: 27 patients received TULSA, with a median follow-up of 16-mo. At baseline, median [IQR] age was 67 years [64–72], PSA 3 ug/l [2.2–6.5], prostate volume 53 ml [45–66], average flow rate 3.9 ml/s [3.3–7], maximum flow rate 10.5 ml/s [7.7–14], voided volume 210 ml [123–335], and post-void residual 71 ml [39–249]. Median sonication, hospitalization, and catheterization times were 42 min, 24 h, and 16 d, respectively. AEs included one grade 1, seven grade 2, and one grade 3 events, including urinary tract infection, urinary retention, and epididymitis (grade 3), all resolving within three months. 16/27 patients have completed their 12-mo follow-up with 2 men dropping off due to cancer diagnosis. Between baseline and 12 months, median values for measured parameters changed as follows: prostate volume (based on the elliptic formula) reduced from 53 to 32.5 ml, PSA reduced from 3 to 1.45 ug/l, post-void residual volume decreased from 71 to 54 ml, average flow rate increased from 3.9 to 8 ml/s, Qmax increased from 10.3 to 18.45 ml/s, voided volume increased from 210 to 300.8 ml, IPSS score improved from 17 to 4, IPSS QoL score improved from 4 to 1, IIEF-5 improved from 15 to 20.5, EPIC-26 urinary incontinence domain improved from 85.5 to 100, EPIC-26 irritative/obstructive domain improved from 62.5 to 93.5, EPIC-26 bowel domain improved from 87.5 to 97.92, EPIC-26 sexual domain improved from 55.58 to 68.75, and EPIC-26 hormonal domain remained unchanged at 95. Results of uroflowmetry, functional status, and QOL questionnaires all improved at 12 months despite discontinuation of LUTS medication in 23/27 men receiving medication before. CONCLUSIONS: 12-mon outcomes strengthen our previously reported results on the safety and efficacy of TULSA as a promising treatment option for BPO. Source of Funding: Profound Medical © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1094 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mikael Anttinen More articles by this author Antti Viitala More articles by this author Pouya Doerwald More articles by this author Pietari Mäkelä More articles by this author Pertti Nurminen More articles by this author Heikki Pärssinen More articles by this author Teija Sainio More articles by this author Ilari Virtanen More articles by this author Pekka Taimen More articles by this author Roberto Sequeiros Blanco More articles by this author Peter J. Boström More articles by this author Expand All Advertisement PDF downloadLoading ...

MP73-05 PIVOTAL STUDY OF MRI-GUIDED TRANSURETHRAL ULTRASOUND ABLATION (TULSA) OF LOCALIZED PROSTATE CANCER: 4-YEAR FOLLOW UP

MP73-05 PIVOTAL STUDY OF MRI-GUIDED TRANSURETHRAL ULTRASOUND ABLATION (TULSA) OF LOCALIZED PROSTATE CANCER: 4-YEAR FOLLOW UP

MP73-15 COMPARISON OF POSTOPERATIVE COMPLICATIONS BETWEEN FOCAL ABLATION AND RADICAL PROSTATECTOMY FOR INTERMEDIATE-RISK PROSTATE CANCER: THE FARP RANDOMIZED CONTROL TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP73-15 COMPARISON OF POSTOPERATIVE COMPLICATIONS BETWEEN FOCAL ABLATION AND RADICAL PROSTATECTOMY FOR INTERMEDIATE-RISK PROSTATE CANCER: THE FARP RANDOMIZED CONTROL TRIAL Eduard Baco, Tigist Alemu, and Erik Rud Eduard BacoEduard Baco More articles by this author , Tigist AlemuTigist Alemu More articles by this author , and Erik RudErik Rud More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003341.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The aim of this study is to report and compare postoperative complications at 1 year, in Clavien-Dindo classification (CD) and Comprehensive Complication Index (CCI), for patients who were treated by Focal Ablation (FA), using high-intensity focused ultrasound (HIFU) or transurethral ultrasound ablation (TULSA), vs. Robot-Assisted Laparoscopic Prostatectomy (RALP) in the FARP Randomized Control Trial. METHODS: 213 men with biopsy-proven unilateral intermediate-risk prostate cancer visible on MRI were randomized 1:1 to FA or RALP with a cross-over rate of 27 % from RALP to FA. 131 patients were treated with FA (108 HIFU, 23 TULSA), and 75 with RALP using a unilateral nerve-sparing technique. Seven patients who were randomized to RALP declined to undergo prostatectomy and remained untreated. All patients were followed for at least 1 year with no drop-out. Complications were prospectively registered in a digital patient journal, entered in the FARP database, and graded according to CD. CCI was calculated as the sum of all complications and weighted for severity. Differences in binary outcomes were assessed with a Chi-square test, while continuous variables were evaluated using an independent sample T-test. RESULTS: Mean age, PSA, index tumor diameter, and prostate volume on MRI for FA vs. RALP were: 64 vs. 66 years, p=0.3; 8.6 vs. 8.5 ng/ml, p=0.9; 14.5 vs. 15.5 mm, p=0.2; and 41.3 vs. 41.7 ml, p=0.9. Grade CD 1 and 2 complications in FA vs. RALP were 17% vs. 25 %, p=0.18. The incidence of serious complications defined as CD≥3 was 2 % vs. 13 %, p<0.001 (Table 1). The mean CCI was 3.9 and 6.9 in FA and RALP, respectively; p=0.08. CONCLUSIONS: FA of prostate was associated with significantly better safety outcomes as compared to RALP considering the frequency and severity of CD grade≥3 complications and across the entire CCI scale. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1041 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eduard Baco More articles by this author Tigist Alemu More articles by this author Erik Rud More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract No. 160 MR Susceptibility-Weighted Imaging During Transurethral Prostate Sono-Ablation Procedures for Guidance of Device Placement to Counter Effect of Intra-Prostatic Calcifications

Men seeking MRI-guided transurethral ultrasound ablation (TULSA) for treatment of prostate cancer (PCa) are screened for calcifications. Large calcifications can block ultrasound (US) and cause inadequate heating. Smaller calcifications (≤3 mm) can be accommodated by aligning the ultrasound applicator (UA) with calcifications between transducer elements. We compare calcification detection and size measurement using susceptibility-weighted MRI (SWI) vs. computed tomography (CT). We also assess the impact of calcifications on ablation coverage benchmarked against a previously published pivotal trial. Pre-TULSA screening for calcifications (calcs) was performed with CT for 17 men. The mean (range) of CT slice thickness was 1.6 (0.6-5.0) mm. When relevant calcs were detected, intraprocedural SWI (1.0-mm slices) was used to guide positioning of UA elements with respect to calcs. Calcification in-plane and through-plane diameters were measured on CT and SWI, and their impact on ablation coverage was assessed using MR thermometry. Maximum temperature and thermal dose maps from MR thermometry were segmented in 90-degree quadrants across the active UA elements, with presence of calcification assessed based on SWI magnitude and phase images. 25 prostatic calcs were identified across 17 men. All calcs identified on CT were visible on SWI. In 4 men, SWI phase images were used to differentiate calcs from iron. Mean (range) diameter was 3.8 (1.4-10.4) mm on CT and 4.0 (2.2-10.8) mm using SWI. SWI diameters were larger by median 22% in at least one dimension for all men and in 42/50 measurements overall. With SWI-guided UA placement in 9 men, median (IQR) proportion of target volume reaching boiling temperature was 4.0 (2-8.0) % and 3.0 (0-7.0) % in sectors with and without calcs based on MR thermometry. Adequate thermal dose was achieved in men with and without calcs: 98 (93-100) % vs 98 (95-100) %. In the pivotal trial of 115 patients, which did not have SWI-guided UA placement, 93% (90-98%) of quadrants with calcs reached adequate thermal coverage compared with 98 (93-100)% overall and 6 (1-9)% with calcs had target volume approaching boiling vs 0 (0-5) % overall. Intraprocedural SWI detected all CT-identified calcifications, tending to overestimate the diameter but guiding effective device positioning. CT remains the gold standard for pre-TULSA calcification screening, and further studies are warranted to optimize SWI protocols, correlate the size of calcifications on CT and SWI, and predict their impact on ablation coverage.

Abstract No. 9 ▪ FEATURED ABSTRACT Pivotal Study of Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (TULSA) of the Prostate: 4-year Follow-up

Abstract No. 9 ▪ FEATURED ABSTRACT Pivotal Study of Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation (TULSA) of the Prostate: 4-year Follow-up

Salvage Transurethral Ultrasound Ablation (TULSA) for localized radio-recurrent prostate cancer: 12-month safety and oncological outcomes

Salvage Transurethral Ultrasound Ablation (TULSA) for localized radio-recurrent prostate cancer: 12-month safety and oncological outcomes

Four-year follow-up of MRI-guided Transurethral Ultrasound Ablation (TULSA) in men with localized prostate cancer

Four-year follow-up of MRI-guided Transurethral Ultrasound Ablation (TULSA) in men with localized prostate cancer

12 months clinical outcomes of Transurethral UltraSound Ablation (TULSA) for benign prostatic hyperplasia

12 months clinical outcomes of Transurethral UltraSound Ablation (TULSA) for benign prostatic hyperplasia

Magnetic resonance imaging-guided ultrasound ablation for prostate cancer - A contemporary review of performance.

Prostate cancer (PCa) is one of the most common malignancies in men, but patient outcomes are varied depending on extent of disease. Radical, whole-gland therapies, such as prostatectomy or radiotherapy, are definitive treatments for PCa, but they are associated with significant morbidity, including erectile dysfunction and urinary incontinence. Focal therapies for PCa, whereby the part of gland harboring disease is selectively treated, spares the normal surrounding structures, and minimizes the morbidity associated with whole gland treatment. The use of magnetic resonance imaging (MRI) guidance provides advantages over ultrasound guidance, such as better localization and targeting of clinically significant PCa (csPCa), as well as MRI thermometry which optimizes tissue ablation temperatures. This review will discuss two MRI-guided high-intensity focused ultrasound (HIFU) techniques - transrectal MR-guided focused ultrasound (MRgFUS) and TULSA (transurethral ultrasound ablation) ablation for localized PCa. Overall, recent major trials for MRgFUS and TULSA have shown promising oncological and functional results in the treatment of low- to intermediate-risk PCa. Recent Phase II MRgFUS trials have shown better oncologic outcomes than the published results for focal ultrasound guided HIFU and may justify the additional costs associated with MRI guidance. While initial studies on TULSA have focused on subtotal gland ablation, recent trials assessing oncological outcomes for focal treatment of angular sectors have shown promise.

Evolving imaging methods of prostate cancer and the emergence of magnetic resonance imaging guided ablation techniques.

Established therapies for prostate cancer (PCa), surgery and radiotherapy, treat the entire gland regardless of the location of the cancerous lesion within the prostate. Although effective, these methods include a significant risk of worsening genitourinary outcomes. Targeted image-guided cancer therapy has gained acceptance through improved PCa detection, localization, and characterization by magnetic resonance imaging (MRI). Minimally-invasive ablative techniques aim to achieve comparable oncological outcomes to radical treatment while preserving genitourinary function. Transurethral ultrasound ablation (TULSA) and next-generation transrectal high-intensity focused ultrasound (HIFU) utilize MRI guidance to thermally ablate prostate tissue under real-time MRI monitoring and active temperature feedback control. Previous trials performed by our group and others, including a large multicenter study in men with localized favorable-risk disease, have demonstrated that TULSA provides effective prostate ablation with a favorable safety profile and low impact on quality of life. Recently, MRI-guided HIFU focal therapy was also shown as a safe and effective treatment of intermediate-risk PCa. Here we review the current literature on ablative techniques in the treatment of localized PCa with a focus on TULSA and HIFU methods.

Safety and efficacy of MRI-guided transurethral ultrasound ablation for radiorecurrent prostate cancer in the presence of gold fiducial markers.

Safety and efficacy of ultrasound prostate ablation for radiorecurrent prostate cancer (PCa) in the presence of gold fiducial markers has not been previously reported. To evaluate safety, functional, and early-stage oncological outcomes for patients with gold fiducial markers undergoing salvage magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (sTULSA) for radiorecurrent PCa. Data were acquired from an ethics-approved, single-center phase-1 study. Eight patients with 18 total gold fiducial markers inside the planned treatment volume were identified. MRI controls were performed at three and 12 months, followed by PSMA-PET-CT imaging and biopsies at 12 months. A control cohort of 13 patients who underwent sTULSA without markers were also identified for safety profile comparison. Adverse events were reported using the Clavien-Dindo classification, and questionnaires including EPIC-26, IPSS, and IIEF-5 were collected. Of 18 markers, 2 (11%) were directly responsible for poor ultrasound penetration. However, there were no local recurrences at 12 months. PSA, prostate volume, and non-perfused volume all decreased over time. At 12 months, 11/18 (61%) of fiducial markers had disappeared via sloughing. The adverse event profile was similar between both patient cohorts, and when controlled for ablation type, no statistical difference in functional outcomes between the two cohorts was observed. Patients with radiorecurrent PCa with intraprostatic gold fiducial markers can be successfully treated with TULSA. The early-stage efficacy of sTULSA for patients with intraprostatic gold markers is encouraging and the safety profile is unaffected by marker presence.