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TULSA Procedure Technique for Prostate Cancer: A Practical Guide

Author Bryant Schmitz covers TULSA Procedure Technique for Prostate Cancer: A Practical Guide on BackTable Urology

Bryant Schmitz • May 6, 2023 • 39 hits

The TULSA procedure (transurethral ultrasound ablation) is a new prostate cancer treatment option that uses real-time MRI thermometry to visualize treatment areas and boundaries. Performed in an MRI suite with involvement from urology, radiology, and anesthesia, the TULSA procedure involves several technical steps, including imaging, device placement, ablation control, and real-time monitoring. Urologists Dr. Xioasong Meng and Dr. Aditya Bagrodia team up with radiologist Dr. Daniel Costa to explain how to successfully treat prostate cancer with the TULSA procedure, including step-by-step guidance on many of the techniques that they use to achieve good outcomes.

This article features excerpts from the BackTable Urology Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable Urology Brief

• The TULSA Procedure is performed in an MRI suite with urology, radiology, anesthesia, MRI technician, and device rep coverage.

• The patient is placed in the semi-lithotomy position under general anesthesia.

• T2 scans are used to assess anatomy, device placement, and for treatment planning (drawing the treatment area). Supplemental diffusion-weighted imaging is used if tumors are difficult to see on T2.

• There are two devices that are required to administer therapy: a urethral applicator and a rectal cooling device. The urethral applicator is placed in the intraprostatic urethra, and the surface of the rectal cooling device is opposed to the portion of the anterior rectal wall that is in contact with the prostate.

• MRI sequences are run continuously throughout the procedure to track temperature and anatomy. A representative from the device company is present during the procedure to assist and collect data.

• Ablation time averages one hour. Total TULSA procedure time is approximately three hours.

• Patients are usually discharged the same day with a catheter and a course of antibiotics. Postbiotic medications, Levsin for bladder spasms, and stool softeners are prescribed. Narcotics are rarely required. Patients usually manage pain with Tylenol or ibuprofen.

• The first follow-up appointment is scheduled for one month after the TULSA procedure. The first PSA test is also scheduled for three months, with quarterly tests for the first year. MRI and biopsy are performed at one year follow-up.

Tulsa procedure technique device placement diagram

Table of Contents

(1) TULSA Procedure: Drawing the Treatment Area

(2) TULSA Procedure Technique: Device Placement, Ablation, and Real-Time Monitoring

(3) TULSA Procedure Post-Operative Care and Follow-Up

TULSA Procedure: Drawing the Treatment Area

To begin the TULSA procedure, the patient is placed in a semi-lithotomy position. The urethral applicator and the rectal cooling device are placed. Quick T2 scans are used to assess the anatomy and device placement, followed by more sophisticated T2s to create a treatment plan. Supplemental diffusion-weighted imaging is used if tumors are difficult to see on T2.

[Dr. Aditya Bagrodia]
They've been consented, they've been adequately warned about all the side effects, and they've gotten their colon prep. Here we are, the day of the procedure. Let's try to really organically walk through what that looks like. First off, location. Is this happening in the hospital, at an ambulatory surgery center, or the same spot where people are getting image-based procedures? Where is this actually taking place?

[Dr. Daniel Costa]
Here, this takes place at our university hospital. The reason being we need access to anesthesia, and that's where we can have that. What we need is anesthesia, MRI, and in our case, radiology and urology coverage. We do this at our university hospital. At the beginning of the procedure, we have the radiologist and the urologist talk to the patient, recap what the treatment plan is, whether it's a hemi-ablation, whether it's a near whole-gland ablation, and we do the time out. Then we have the urologist place the devices. These are two devices, the urethral applicator and the rectal cooling device.

The patient is imaged, and we assess for the device location. You want to make sure that the urethral applicator is in the intraprostatic urethra and that thing, the surface of the endorectal cooling device is just opposed to the portion of the anterior rectal wall that is in closer contact with the prostate. We want to make sure that there is no air between the endorectal cooling device and the rectal wall because that air can also misinform the system about temperature during the temperature monitoring that feeds the system and controls the energy delivery. Once those steps are taken care of, after we determine that the devices are in the proper position, we start to draw the treatment plan.

[Dr. Aditya Bagrodia]
Sorry to interrupt. Is this done supine? Is this done lithotomy? How is the patient positioned?

[Dr. Daniel Costa]
It's a semi-lithotomy. There are leg extenders that keep the patient in that position under general anesthesia.

[Dr. Aditya Bagrodia]
The sequences, are those T2s or are you getting multiple modalities? What's the typical protocol?

[Dr. Daniel Costa]
The first set of images are very quick T2s to see the anatomy and how it relates to the location of the devices. Then as we know that the devices are in the right position, we'll get slightly more sophisticated T2s that give a better depiction of the anatomy. That will be the basis for drawing the area to be treated. Those are images that give us very good view of the tumor, neurovascular bundles, the external sphincter. It really sets the foundation to draw the treatment plan. We can also supplement that with a diffusion-weighted imaging in patients who have cancers that are difficult to see on T2, but that's rarely required.

Listen to the Full Podcast

TULSA-PRO: A Practical Guide for Setup and Success with Dr. Daniel Costa and Dr. Xiaosong Meng on the BackTable Urology Podcast)
Ep 94 TULSA-PRO: A Practical Guide for Setup and Success with Dr. Daniel Costa and Dr. Xiaosong Meng
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TULSA Procedure Technique: Device Placement, Ablation, and Real-Time Monitoring

The TULSA procedure involves placing a urethral applicator and a rectal cooling device, which is followed by taking MRI sequences to ensure proper positioning and treatment planning. The treatment requires constant monitoring and adjustments to address gland swelling, bladder fullness, and other factors that may affect the procedure's success. Real-time MRI feedback is used to monitor temperature and anatomy throughout the procedure, although detecting changes can be nuanced. Company support, urologists, radiologists, anesthesiologists, and MRI technicians all play vital roles in the TULSA procedure.

The average ablation time for a TULSA procedure is around one hour, but the entire process, including anesthesia, patient positioning, device placement, and post-treatment steps, typically takes around three hours.

[Dr. Aditya Bagrodia]
Then for the actual urethral applicator placement, is that a cysto wire over a wire, or is that just placed like a catheter?

[Dr. Xiaosong Meng]
We do a council tip catheter first, empty out the bladder, put a little bit of fluid back into the bladder, super stiff wire, and then we put the urethral applicator over the super stiff wire. If it's a rigid urethral applicator, so like putting in a rigid cystoscope, it usually goes in no problem over the wire.

[Dr. Aditya Bagrodia]
Perfect. The rectal cooling device, that's roughly what diameter? Are you doing anything on the front end? I'll tell you why I asked this, is I had a colleague of mine doing a HIFU case and post-radiation, and the patient had fairly significant anal stenosis. Suffice it to say that that was a deal breaker day of surgery. Any kind of assessment of that going into this?

[Dr. Xiaosong Meng]
It's a decent diameter. I don't know the exact dimensions of it. I would say it's probably at least 2 centimeters across. Certainly, if you have trouble getting your finger in the rectum for a DRE, probably not a good candidate for this. I know Dr. Lotan had treated a patient post-radiation with pretty tight anus, and he did have a little bit of struggle getting it in.

[Dr. Aditya Bagrodia]
If you had, I guess, a fairly uneventful prostate biopsy with a transrectal probe, is that usually going to be okay?

[Dr. Xiaosong Meng]
Yes, I think that's actually a good benchmark.

[Dr. Aditya Bagrodia]
Great. I hope these details aren't boring for you guys. I just want to make this some of the practical consideration that I've thought about and maybe others have thought about. We've just gotten to placing our urethral applicator and our rectal cooling device and now we're taking our sequences, making sure that things are in the appropriate position and drawing out our treatment plans.

[Dr. Daniel Costa]
That's right. When deciding what to treat, we normally already had that conversation with the patient and urology and radiology already extending information. We already go into the treatment day knowing what we plan to do. When we get those images, then it's a matter of putting that in practice. We will find where the cancer is. Let's suppose it's as focal as can be treatment. We find the cancer, we try to have at least a one-centimeter safety margin in as many directions as possible so that almost invariably results in a minimum of, as Xiaosong was saying, a quadrant ablation.

It's very uncommon that you'd have such a small lesion that you'd be able to get away with blast in that the way the system works is you have different elements in the urethra probe. Each element, you can think of it as a five-millimeter slab in the transverse direction of the prostate. You can turn on or off those different slabs and that's how the treatment operates. You choose which elements you're going to use and what is the transverse section of each of those elements that you want to the ablation to happen. Then you choose if you think of the prostate as a clock face, you will choose where you want to start, let's say at twelve o'clock or at three o'clock.

Then in which direction, clockwise or counterclockwise since the probe sweeps in one of those two directions. Usually, what we want to do is to start treating where the cancer is because if something happens, if we have to abort or if there is swelling as we are treating the area that is the most critical region to be covered has already been covered. Once we do that first sweep, we normally do at least a second sweep where the MRI visible lesion is, and we tend to do that in the opposite direction of the first suite.

What we noticed is in some men that have tiny classifications or that have some tissue properties that we can't recognize but result in a suboptimal heat distribution, sometimes we have a much better heat distribution when we are coming in a different direction. This is something that hasn't been studied, but it's a consistent anecdotal observation at our center and in other centers as well.

[Dr. Aditya Bagrodia]
It certainly sounds like this is where the battle for a good cancer procedure is going to be won and lost, which is going to be careful contouring really being dialed in on temperature maximums at various different time points. Some of it sounds like a repeat freeze-thaw cycle of cryoablation with the multi-pass that you're describing here, but this is where I'm guessing it's going to be a little bit more technologically involved and ostensibly, you're going to get fairly heavy support at least early on from your local representative. Is that true?

[Dr. Daniel Costa]
Absolutely, yes. It is easy to watch a video of what a TULSA Procedure looks like and think that it's a plug-and-play technology, that you just push a button and you are there waiting for the procedure to be done before you say goodbye to the patient but that's not true. It requires close monitoring during the treatment as Xiaosong alluded to, and that's something that we learned after maybe 10, 15 patients that we had treated, it's very common for the gland to swell in response to the heating.

If you're dealing with a very peripheral lesion, especially postural lateral lesions, it's very easy to go unnoticed that the lesion with the swelling now falls outside of the originally drawn area and that can be easily a source of undertreatment and cancer and repeat biopsy. It's important to monitor, and that's one of the strengths of TULSA, is the ability to do so. You can see that the gland swelling or that the bladder is getting fuller and therefore this result in a little bit of a change in some displacement at the base of the prostate, so recognizing that and responding to it is a critical step in order to have adequate treatment.

[Dr. Aditya Bagrodia]
How often are you running your MRI sequences? Forgive my ignorance, you're obviously on a-- If it's an ultrasound and it's HIFU, you can look at cavitation or if it's cryo, you're looking at the ice ball. We don't have any real-time monitoring here, so is it just, let's run the T2 again, and how long does that take and how often are you doing it?

[Dr. Daniel Costa]
It's throughout the procedure. It never stops from beginning to end, the scanner is running and so you are getting that feedback every five, six seconds. You get a new frame that shows you what the temperature is and what the anatomy looks like. Now, I should disclose that the anatomic depiction that we get every five, six seconds is not that phenomenal T2 that you can see everything very clearly. These are images used for the temperature monitoring that allow you to get a sense of where those interfaces are, where the interface between the prostate and the periprostatic fat is. It's nuanced. You really have to be looking for this.

It's not something that pops out and it's so obvious that the gland is swelling and that's one of the reasons why there is a learning curve and it requires constant monitoring.

[Dr. Xiaosong Meng]
Going back to your question earlier, Aditya, about the support from the company. There is always someone from the company there for their treatment and even now, 120 cases in, someone still comes, they record data, they do a lot of granular data in terms of how long are you taking to prep the room, put the devices in, do your planning, your treatment, any issues. That's one nice thing about it is that you'll have an expert from the company there to at least help you. Then sometimes it's like the MRI machine's not working, and they'll help you kind of troubleshoot some things like that with the MRI techs, which is helpful.

[Dr. Aditya Bagrodia]
I guess so in addition to the urologist radiologist, anesthesiologist, you would need an MRI technician as well, is that correct?

[Dr. Xiaosong Meng]
Yes, there's usually at least two or three around [chuckles] coming from the OR is nice, there's so many people around to help out. Going back to one of your earlier questions about the different areas, so we do it obviously in the hospital. They do have free-standing imaging centers where urologists can bring patients to treat. There's a mobile van now or a mobile truck that they can treat, and some of these are done in the OR, like the OR at St. Louis University, they're doing theirs in their MRI suite in the OR. It's a whole variety of different areas of where people are getting treated.

[Dr. Aditya Bagrodia]
Then like a typical straightforward quarter or hemi-gland, that's going to be three hours. My understanding is that your experience as well of course there's going to be patient-specific variability. Is that typical?

[Dr. Daniel Costa]
Yes, so the ablation time, which is one of several steps in the entire treatment time is directly dependent on the volume of ablation and the number of sweeps that we choose to do. The quickest ablation we can do is 20 to 30 minutes, but the average ablation time is around one hour. Now, when you add the other steps, so general anesthesia, patient positioning, device placement, in many instances, the devices need to be repositioned or there is an annoying air bubble that needs to be addressed. Then removing the devices, putting the Foley catheter and waking up, it's usually a three-hour procedure time.

TULSA Procedure Post-Operative Care and Follow-Up

Patients are typically discharged the same day of the TULSA procedure and are given antibiotics, postbiotic medications, and other prescriptions to manage postoperative side effects. The first follow-up appointment is scheduled one month after the procedure, with the first PSA test at three months. The initial year includes quarterly PSA tests, followed by an MRI and biopsy at the one-year mark.

[Dr. Aditya Bagrodia]
Then so you've completed the procedure, you place a catheter and several hours in the PACU standard discharge criteria, and then you've gotten through it, is that right?

[Dr. Xiaosong Meng]
Yes. I think maybe we have one or two patients stay because it was late but for the most part, everyone goes home same day, catheter, they get a few days of antibiotics, they get a course of postbiotic medications. We do Levsin to help them with bladder spasms, stool softeners. I don't have to give any narcotics. It's pretty rare. Most of the time these patients do just fine or Tylenol or ibuprofen. They go home and then I'll see them a month out. I'll see them a month out to check in on them, see how they're voiding. I usually give them some time to let the inflammation and stuff cool down. We'll see about one month.

If they're on the clinical trial with CAPTAIN trial, they'll get a PSA at one month. Otherwise, I usually get my first PSA at three months and we do PSAs every three months for the first year and then MRI and biopsy at one year.

[Dr. Aditya Bagrodia]
This is fantastic. I think it at least walks us through in some detail, patient selection, the day off and at least that early follow-up up to a year then clearly there's going to be some schedule of PSAs and MRIs and biopsies over the ensuing timeframe and Xiaosong I think you very nicely discussed how this is a commitment from all the key stakeholders here. There's still some prostate that hasn't been treated and so on. Incredibly valuable and maybe now we'll just shift gears a little bit about starting the program, maybe a walk down memory lane and I'll share an experience.

Podcast Contributors

Dr. Daniel Costa discusses TULSA-PRO: A Practical Guide for Setup and Success on the BackTable 94 Podcast

Dr. Daniel Costa

Dr. Daniel Costa is a diagnostic radiologist and an associate professor of radiology at UT Southewstern in Dallas, Texas.

Dr. Xiaosong Meng discusses TULSA-PRO: A Practical Guide for Setup and Success on the BackTable 94 Podcast

Dr. Xiaosong Meng

Dr. Xiaosong Meng is a urologist and assistant professor with UT Southwestern in Dallas, Texas.

Dr. Aditya Bagrodia discusses TULSA-PRO: A Practical Guide for Setup and Success on the BackTable 94 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2023, April 26). Ep. 94 – TULSA-PRO: A Practical Guide for Setup and Success [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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