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TULSA Prostate Treatment

Author Bryant Schmitz covers TULSA Prostate Treatment on BackTable Urology

Bryant Schmitz • May 6, 2023 • 904 hits

TULSA prostate treatment is a new prostate cancer treatment option that uses real-time MRI thermometry to visualize treatment areas and boundaries. TULSA treatment for prostate cancer requires proper patient selection and preparation are crucial for success, like other prostate cancer therapies. Urologists Dr. Xioasong Meng and Dr. Aditya Bagrodia team up with radiologist Dr. Daniel Costa to explain the ideal patient for TULSA prostate treatment (transurethral ultrasound ablation), absolute and relative contraindications, how to prep patients for treatment, potential side effects, and expected 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

• TULSA prostate treatment can treat a wide range of patients. The ideal TULSA prostate treatment candidates are intermediate-risk with localized, focal disease.

• Selection criteria for TULSA prostate treatment consider tumor location, proximity to critical structures, patient priorities, and individual risk factors. Anatomical characteristics influencing TULSA decision-making include lesion location, focality, prostate size, and cancer grade.

• Lesion size is not a limiting factor, but proximity to critical structures can be. Factors like urinary sphincter proximity, neurovascular bundle proximity, and bladder neck proximity may impact treatment decisions and necessitate trade-offs.

• Significant prostatic calcifications can impact treatment success. Accordingly, prostate MR protocol has been adjusted to identify prostatic calcifications and streamline patient workup.

• TULSA can be used for salvage post-radiation and in patients with lower-risk disease and lower urinary tract symptoms (LUTS). TULSA can also be customized to treat focal, hemi-gland, or whole-gland ablation depending on cancer characteristics and patient preferences.

• TULSA Contraindications may include previous prostate procedures, median lobe involvement, and presence of clips in the prostate.

• Urethral strictures can also be a contraindication for TULSA treatment due to the potential for worsening symptoms.

• Patients with UroLift devices, fiducial markers, or brachytherapy seeds need careful evaluation to ensure quality treatment. Median lobes, large prostates, and previous TURP or green light treatments can still be managed with TULSA. 5-ARI regimen can be used to shrink the prostate, making treatment possible in borderline cases.

• Careful patient preparation and counseling are required to manage expectations and potential complications. Patient preparation for TULSA prostate treatment involves MiraLAX prep, clear liquids for 1-2 days, enema before the procedure, and glucagon to decrease rectal wall motion.

• Dr. Meng cites HIFU trials when discussing prostate cancer recurrence. He estimates a 20-25% chance of recurrence for true focal treatment, while whole-gland treatment may have lower recurrence rates. The TACK trial 4-year outcomes showed 16% of patients underwent additional treatment following TULSA.

TULSA prostate treatment device

Table of Contents

(1) TULSA Prostate Treatment Candidates

(2) TULSA Prostate Treatment Workup & Considerations

(3) TULSA Prostate Treatment Contraindications

(4) TULSA Prostate Treatment Side Effects

TULSA Prostate Treatment Candidates

Doctors discuss TULSA prostate treatment candidates and the technical aspects affecting patient selection. Intermediate-risk patients with localized and ideally focal disease are considered ideal candidates. Lesion size is typically not a limiting factor, but the distance from critical structures like the external urethral sphincter, neurovascular bundles, and bladder neck is important. The presence of significant calcifications in the prostate can also affect treatment outcomes. The discussion also highlights the importance of real-time MRI imaging for treatment planning and controlling the degree of heating.

[Dr. Aditya Bagrodia]
Daniel and I were talking before we actually formally started. It's a little bit tricky and challenging now with the direct-to-patient advertising, medical centers advertising, and so on and so forth where I've got patients with grade group five prostate cancer coming in and say, "Hey, doc, I want to receive HIFU," or they have grade group one prostate cancer and they're like, "Can I get lutetium PSMA treatment for my grade group one prostate cancer?" You're having to explain that this is a very heterogeneous disease. Every patient's a little bit different. With that, who are your ideal patients when a new diagnosis comes in? What are the features that you're like this might be a good patient for TULSA.

[Dr. Daniel Costa]
In our case, our ideal patient is the intermediate-risk patient with a localized disease. Ideally also focally. It's certainly easier to treat lesions that are either in the lateral or anterior portion of the gland where you're less concerned about injury to either a neurovascular bundle. A medium-size prostate, because there is a maximum radius that the ultrasound beam can reach, so if the lesion is more than 3 centimeters away from the urethra, we may have trouble reaching that region.

We certainly want to also exclude large calcifications in the prostate that could act as a shield, a barrier that prevents the ultrasound beam from reaching the area to be treated. Also, a patient that we are eager to treat are patients who had radiation and have recurrent disease. Salvage post-radiation is usually a good patient for TULSA. Also, although not the core of our patient population, some patients with lower-risk disease who are extremely uncomfortable with the idea of active surveillance and that happen to have LUTS because we can tackle both BPH and the cancer at the same time.

[Dr. Aditya Bagrodia]
Fantastic. A couple of questions. You mentioned significant calcifications. Is that something that is standard reporting when you're doing an ultrasound biopsy for instance, or are you getting some type of imaging, non-contrast CT, or so forth to assess?

[Dr. Daniel Costa]
Yes, as we learned that calcifications play such an important role in patient selection, we tweaked our prostate MR protocol so that when a patient comes to get a diagnostic MRI, there is a sequence that aims specifically at identifying calcifications in patients who are referred from outside institutions and did not get an MRI with us. Some of them may require a CT of the pelvis to look for those calcifications. Ultrasound in theory can see calcifications, but because there is not a standard approach to how this is done, it's hard to retrospectively look at those images and be sure that the patient did have appropriate screening for those classifications.

[Dr. Xiaosong Meng]
I think Daniel's really led to charge there in terms of helping us work up our patients better with the issues with calcifications, because it's not only size, it's location. If it's a calcification on the other side of the prostate that you're not ablating, you really don't care about it. I think that's where the cross-sectional of imaging comes into play. The fact that we're able to get this part of every single diagnostic MRI has really helped speed up the process. Now we're not asking patients, we're going to another CT, we'll figure out if you're eligible for TULSA. It's like, here's your lesion, here's your calcifications. It's all in the same imaging sequence. I think that's really streamlined the workflow there.

[Dr. Aditya Bagrodia]
Daniel, you mentioned size of the prostate, what about size of the lesion? Is that a relative or absolute contraindication?

[Dr. Daniel Costa]
It doesn't seem to be. What you want to make sure is that the lesion is not too close to the sutures that you don't want to cause any damage to, so the external urethral sphincter, the neurovascular bundles, the bladder neck, but a large lesion in an ideal location should not be an issue just because it's large. Going back to the calcifications discussion, also an example of how we are learning about the technology as we use it.

In some men with large calcifications in a location where we do not see that as a problem, we sometimes see that large calcification as not really as much of a barrier to energy delivery as we thought it would be. In some men where we do not see any large calcification, we sometimes see a challenging penetration of that tissue. We are learning that there might be some tissue properties that interfere with the ultrasound dissipation and the heat distribution that we are not as aware of today as we'd like.

[Dr. Aditya Bagrodia]
You mentioned proximity to critical structures; the sphincter, the bladder neck, and the nerves. Generally the way I think about it for most of the ablation technology is the apex is a bit tricky. Is that true in your estimation for HIFU, or is this an area that's a little bit more amenable to HIFU?

[Dr. Daniel Costa]
That is true. We like to have at least a 5-millimeter distance from the US. It's also interesting because each man, the anatomy is slightly different from one another. The angle, the steepness of the angle that you see the apex, and the relationship between the US and the apical-most portion of the prostate. We sometimes see a US that is almost intra-prostatic. Whereas in some men there is a larger distance between those two structures. I would say these aren't set in stone, these numbers, and we really need to look at every single patient in that to see if he is a good candidate or not. That takes quite a bit of time, and it's an involved process for sure.

[Dr. Xiaosong Meng]
I do feel one thing about-- we've treated a few patients where the tumor is almost touching the external sphincter. I think you can position the device in and out. You can put where your last ablation element is, and you can put it very close to the sphincter. So far, for the few guys that we've treated where the tumors were touching the sphincter, they've not had stress urinary incontinence, which I find encouraging.

They certainly have more LUTS in the short-term, I think from swallowing other treatment, but at the moment I think for those that are very, very close, I think we're able to skirt the fine line. Because of how detailed the anatomy is, you're getting real-time MRI images to do your planning, and the ability to control the degree of heating, I think is very good. Then that certainly, I think, is one of the benefits if you're treating things close to critical structures with this technology.

[Dr. Aditya Bagrodia]
Now that's good to know. When I came to UC San Diego with recently purchased the capital equipment for HIFU, and I had in my mind as somebody that was going to be offering this treatment to patients, that I wanted them to be ideal favorable intermediate-risk posterior lesions MRI-detectable, rest of the prostate negative on systemic biopsies. Fast-forward about nine months, I'd done one HIFU and I had to slightly extend the criteria.

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 Prostate Treatment Workup & Considerations

The doctors discuss the patient selection process and treatment considerations for TULSA prostate treatment. They emphasize the importance of multidisciplinary discussions, the need for close follow-up after treatment, and the factors that may influence treatment decisions. Additionally, they address the flexibility and customization of TULSA, oncologic outcomes, and quality of life preservation.

[Dr. Aditya Bagrodia]
It sounds like perhaps as you guys have obtained more experience, it may go from the perfect patient, if you will, to somebody that there's going to be a little bit of a trade-off, a little bit of managing some risk and uncertainty. Quick question. Are these patients currently being done on trial mostly, or is it a multidisciplinary, you've had a chance to discuss surveillance radiation surgery, ablation, the consensus is ablation via TULSA?

[Dr. Xiaosong Meng]
These patients come in both ways. They either come in to see me directly or see one of the partners, and they get referred to me for discussion on TULSA or they'll come and see Daniel from radiology. Then Daniel will talk to them and then send it to me, and I'll broaden the discussion a little bit. Some patients come in just with the diagnosis of prostate cancer, and we tell them this is one of the options. I'll counsel them extensively in terms of surveillance, radiation surgery, and the fact that we have these different focal modalities including both TULSA and IRE.

That's one of the ways we counsel them about it. Some patients are coming just for TULSA. I'll have to take a step back and be like, have you thought about this, have you thought about that in addition to TULSA as an option? Going back to, I think, what you were talking about in terms of selection criteria, I think TULSA and HIFU are slightly different because HIFU is coming rectum up. I actually feel that the anterior lesions are some of the best patient outcomes I get with TULSA. These guys will leave very nice margins around the neurovascular bundle.

They're having sexual activity before they even see me at one month. I usually tell them, let's hold off for a month, but these guys are [unintelligible 00:14:58] it's working and they'll be like, "I ejaculated blood." I'm just like, "I asked you to hold off for a little bit." Certainly, I think those are the ones because even if we're gentle near the nerves for posterior tumors, I think they're, just from the local effect inflammation, some of them will have erectile dysfunction temporarily. We see that in the TACK trial, we see that in our data as well.

[Dr. Aditya Bagrodia]
One of my initial patients, just to be quite frank, was a patient, and this is for HIFU with an anterior lesion, and I didn't know that you couldn't bypass the posterior parts of the prostate in terms of no ultrasound energy prior to getting to the apex. Fortunately, I had a senior partner that was practically with me, we were able to manipulate the catheter, and so on and so forth.

It is nice that the critical structures, broadly speaking, are more peripheral, and particularly the nerves of course, and you have an opportunity to get away from those. Ablation, there's focal ablation, there's hemi-ablation, there's hockey stick ablation, there's whole-gland. How do you think about this when you're looking at multifocal tumors, bilateral tumors? What is the capabilities or limitations of TULSA?

[Dr. Daniel Costa]
I think that's a major strength of TULSA, is the ability to really customize and literally draw what you want to treat. That is a two-edged sword. It's great to have that ability, but at the same time, it puts on us the responsibility to use it wisely. In order to do so, we have to have a conversation with the patients that allow us to understand what's their priority. These aren't usually a very straightforward conversation because we really have to grasp what's their baseline function urinary and sexual function-wise, and what they value the most when it comes to balancing oncologic outcome and quality of life preservation.

I can certainly tell that at the beginning, there was a trend towards being more focal. As we learned and as we got cancer on repeat biopsies, and as we start to expand the volume of ablation and not see a higher rate of complications or a more cumbersome recovery, our more recent trend is towards having larger volume ablations, provided that we can safely avoid those critical structures that we want to stay away from. It is a conversation between all the stakeholders. That includes the wife that is in the visit with us. It's an opportunity to really go over this. Also, on the day of the TULSA treatment, the radiologist and the urologist are there talking to the patient, recapping the plan, and making sure that we are all on the same page.

[Dr. Xiaosong Meng]
I think part of that goes to the workup that we do before TULSA. We'll do your full bladder scans. For some of the guys, I'll even do the proudP up so we'll get home baseline urinary function to see if, do we want to treat your BPH? How is your baseline sexual function? Some of these patients will come in wanting to preserve as much of ejaculate volume as possible. I'd say, guys, we're treating cancer here. Ejaculate volume is secondary to cancer control. I think certainly it's this whole spectrum of-- I think TULSA, and I agree with Daniel, it's very easy to just almost do whole-gland.

Certainly around the US, about half the treatments from last year have been whole-gland, the rest are more focal than that or hemi-gland. I think part of it is also your systematic biopsies. If you have cancer on your systematic biopsy cores, that may be in a slightly different location. You may be more inclined to say, look, we should probably treat whole-gland to decrease contralateral disease recurrence and things like that.

[Dr. Aditya Bagrodia]
We've actually, for patients that have an elevated PSA and MRI with the focal lesion, and they're getting their MRI ultrasound fusion biopsy, many times, if even the thought of focal is entering our brains, get halo biopsies like has been described by the UCLA group, just to avoid that recurrence near the field. Then it sounds like probably over time when you look back at things, you're like, huh, we're getting a little bit more of an infield recurrence than we might like, and we can expand our ablation volume. I think we've largely covered cancer characteristics. Just a couple questions. Daniel, you mentioned intermediate risk. Does favorable versus unfavorable weigh into that at all?

[Dr. Daniel Costa]
It does not.

[Dr. Aditya Bagrodia]
So 4 + 3 = 7, that's still going to be an acceptable patient. Then my understanding, Xiaosong, is that you did suggest that whole-gland ablation is absolutely a viable option. If you have patients with, say, a clinically significant cancer, whether that's 3 + 4 = 7, 4 + 3 = 7, I'd say the left and the right it's got a couple of cores or grade group one. Would you typically treat the whole-gland, or would you maybe downgrade them to surveillance patients?

[Dr. Xiaosong Meng]
That's a great question. I think part of that is what the patient wants. It's obviously the long conversation in terms of counseling. I think the majority guys are okay with you treating as much as we can of the prostate, but certainly, I tell my patients when I counsel them on focal is that this is like actor surveillance plus we're treating your cancer, and then we're putting you right back on surveillance. If you're someone who's not going to be willing to do MRIs, you're not going to be willing to do PSAs, close follow-up, you're probably not a good candidate for focal.

Compared to surgery or radiation where it's just blood test every few months, this requires we mandate a MRI at one year, we mandate a prostate biopsy at one year on some of the trials like CAPTAIN trials, some MRI plus biopsy in one and two years on the IRE trials mandated biopsy. I tell these guys, look, this is not a one-stop and done. It's a long process. It's a relationship between you and the urologist and the radiology of Daniel when they come back for their biopsies and MRIs that you need to have close follow-up.

[Dr. Aditya Bagrodia]
Perfect. We'll dig into that once we've gotten through the treatment. Patient characteristics maybe to summarize their location really ideally not next to the urinary sphincter, preferably not near the neurovascular bundles or the bladder neck. Those are of course going to be conversations of there may be some give and take here. If you could do a unilateral nerve spraying, for instance. Focality doesn't seem like it's a driver here that you can treat as much of the prostate as you want. Size, more of a prostate size 3-centimeter criteria than a lesion size.

TULSA Prostate Treatment Contraindications

The doctors discuss TULSA prostate treatment contraindications and how to manage lower urinary tract symptoms. The discussion highlights that certain factors, like urethral strictures, may make TULSA prostate treatment unsuitable for some patients, while others, such as median lobes or large prostates, can still be treated with appropriate care. The experts also address the potential impact of previous treatments like brachytherapy seeds or fiducial markers on TULSA treatment, explaining that they may cause challenges but can be managed case-by-case.

[Dr. Aditya Bagrodia]
Apex, again, not ideal, but case by case manageable, and then contra level grade group one, have a conversation about it. Now, one of the things that was intriguing to me, Daniel, is when you mentioned a grade group one patient with LUTS. Maybe let's talk about a little bit of patient characteristics, further anatomy, median lobe, erectile function, urinary function, previous TURP, previous euro lift where they may have some clips in their prostate. Do you want to maybe talk about some relative and absolute contraindications from your end?

Do you want to maybe talk about some relative and absolute contraindications from your end?

[Dr. Daniel Costa]
Sure. What we do know is the ultrasound beam can reach and we can measure temperature reliably within a 3-centimeter radius. That's guaranteed. Beyond that, it's uncertain. If you have a man with a prostate and a lesion that is borderline at that radius or beyond that radius, you may find yourself in a position where you can't really reach that region and therefore unable to treat that man properly. What we've done in some men is with those men on a 5-ARI regimen to shrink that prostate and repeat imaging to reassess the anatomy.

In most men, that was successful because what happens is most of those men, you were borderline 3 centimeters, 3.2 centimeters and then after three months on 5-ARI, we see a 10%, 15% volume reduction that brings that area to within the reachable area. In regards to clips, seeds, I don't think any man has been treated with a UroLift device. There have been patients not at our institution where the UroLift device was removed and then treated, but I don't have direct information about how that went. We've treated patients for salvage post-radiation with both fiducial markers and brachytherapy seeds.

The fiducial markers, I think it's a similar concept to the calcifications. These foreign bodies, they introduce noise in the images that measure real-time temperature that can affect the quality of the treatment by providing poor quality information to the system that is meant to modulate the output of energy. It may appear, for example, as if an area that has not been heated yet is extremely hot even though it isn't. Then the system will not deliver energy to that region because it assumes that that is already a hot area.

Whenever we are assessing a patient with those metallic lips, be it fiducial marker or brachytherapy seed, what we want to make sure is that those areas, how they relate to the area that we want to perform the ablation. In some men, what we can do is we can run a simulation. We bring the patient and run a thermometry map to see how much noise would be generated by those clips or those seeds.

The men that we treated after going through this vetting process, they did not seem to be an issue. We don't have long-term outcome data for those men, but the impression from the day of the treatment was extremely favorable. It does require quite a bit of care when drawing the treatment area on the day of the treatment to make sure that we do not include voxels that could misinform the system and result in undertreatment of critical regions.

[Dr. Aditya Bagrodia]
This may sound like a dumb question, and I should have probably covered a little bit about the mechanism of action for TULSA. We've got this probe in the urethra and it's able to send high-intensity ultrasound waves from the inside out. I'm thinking of a brachy patient, let's say they've got seeds throughout, and let's say they've got some brachy seeds anterior to their urethra and you want to treat something even more anterior to that, for instance. Can your ultrasounds penetrate through those brachy seeds, or is that going to be like where they stop similar to a calcification? You mentioned the impact on thermometry, but what about the effective treatment getting to the area of interest?

[Dr. Daniel Costa]
You are right in the sense that the urethral probe has elements that deliver ultrasound that results in tissue heating. The way it works is the system uses the pixels closer to the periphery of the area that we drew as the area to be treated. To reform the system, that sector has already been heated properly. It assumes that if it's hot at the periphery, that entire sector has been properly heated. That's how it knows whether or not to continue to deliver energy in a certain region or move on to another region.

In regards to whether those clips or mark or fiducial marker or brachytherapy seed could be a physical barrier to the ultrasound beam penetration, what we notice on an MRI in a patient with recurrent post-radiation cancer is that the cancer, as it grows, it moves the seeds away. It's actually when we're reviewing these patients, when we're interpreting these images, we always look for areas where we don't see that many seeds.

Because those are areas that either there is something growing that is pushing the seeds apart, or maybe there weren't seeds there to begin with and that's the area where the treatment failed. That helps us because that is the area that we want to ablate. In general, there is a posity of seeds in those regions. That may not be true for the fiducial markers but because the fiducial markers tend to be put in a structured fashion and they are so few, it's uncommon that they will be riding a critical location, but it has to be evaluated case by case.

[Dr. Aditya Bagrodia]
Fantastic. Then just going back to the lower urinary tract symptoms, are these patients, are they getting pre ablation? You mentioned the 5-ARIs which may help out with symptoms, if they've got a larger prostate, median lobes, does that impact anything at all? History of strictures, previous TURP, or if they have significant frequency urgency, are those contraindications, or how do you synthesize all of their lower urinary tract symptoms, previous BPH history when you're considering treatment?

[Dr. Xiaosong Meng]
That's a good question, because certainly these guys are a little bit more complex to treat. We've had a few guys with urethral strictures where we've basically said, look, it's not a good idea. You've already had two urethroplasties doing this, I think it's a 22-French urethra applicator and it's in there for two to three hours. Could certainly cause damage and worsening of your stricture. We've had a few patients where we said probably not the best idea to consider TULSA for you. We have treated patients who have had prior history of TURP, green light, things like that, and it seems to be okay.

We've treated some patients with median lobe. You have about a 5-centimeter reach. Not only do you have 3 centimeters from the urethra out to the periphery, the actual length, there's 10 elements, they're 5 millimeters apart, so you actually have 5-centimeter treatment length within the prostate and you can also pull back and treat more, so if you have a longer prostate. Certainly we can treat median lobe, you just basically shut off the beam because you do worry about some transmission within the urine to the bladder wall. That's one of those areas that we're very careful of if you're treating a median lobe.

These guys do have a lot of urgency, frequency. The more volume we treat, the more symptoms they have. I think, in some ways, it's probably like Rezum. You're heating up the prostate. In Rezum, you're injecting steam into the prostate, here we're heating the prostate about 55 degrees at the periphery. Certainly hotter inside when they get swelling. They have decent obstructive symptoms for the first four to six weeks, is what I usually counsel my patients.

You're going to be miserable for the first month, and things will slowly get better and better. They get put on alfuz, so they get put on Rapaflo to start before and after the procedure to help with some of the LUTS. The more we treat, the longer I'll leave the catheter in up to about two weeks for these guys with large 60, 70 cc prostates where we do near whole-gland ablation on. We're also starting to explore some of the other things, maybe giving of course of steroids to help with inflammation, NSAIDs, and things like that to really help with their symptoms afterwards.

[Dr. Aditya Bagrodia]
It's like you were reading my mind, Xiaosong, I was going to ask for your spiel/consent process for we've identified the patient, and if I may, it sounds like symptomology isn't a contraindication, they've got a AUA symptom score of 22 or so. Could this be a reasonable benefit to them from a lowering symptom perspective once they get through that initial four to six-week post-treatment inflammatory irritation episode?

As you all know, we've treated men with larger prostates or significant LUTS that are going on to receive radiation. Many times we'll do a TURP or so forth on the front end, or a median lobectomy, or whatever has been decided in conjunction with the radiation oncologist. How do you factor that in? Is that a relative or an absolute contraindication?

[Dr. Xiaosong Meng]
For LUTS alone, I don't count that as an absolute contraindication. It certainly is one of those. It's counseling, and occasionally I'll send them for urodynamics. If their symptoms are really bad or they're having urgency incontinence already, I'll send them for urodynamics to get a good baseline. When we looked at our data, looking at IPSS, looking at guys using Flomax or Rapaflo, about a third of them actually have improved IPSS scores at six months.

I think the vast majority of them are stable. We do have, I think, less than 10% of them who have worse IPSS on follow-up. It's certainly we see a change at three months, it's a better change at six months. Just like those guys that we TURP with LUTS, they will improve. It's not the immediate effect after a TURP or the slow bladder remodeling, but we do see it. Usually, I tell them it's months. It's not anything quick. It's going to be on the order of probably three to six months.

TULSA Prostate Treatment Side Effects

Preparation for TULSA prostate treatment includes a thorough colon cleanse to decrease bowel motion and improve MRI thermometry. Patients receive glucagon to reduce rectal wall motion and are informed about potential side effects such as reduced semen volume, urinary frequency and urgency, effects on erections, and small risk of retention. Cancer control expectations are also discussed, with focal treatment having a 20-25% chance of recurrence, and the TACK trial showing that up to 16% of patients underwent additional treatment with TULSA within 4 years.

[Dr. Aditya Bagrodia]
Now the decision has been made, they don't have any calcifications or relative or absolute contraindication, and appropriate of such a patient in your mind. What is that, here's what to expect leading up to the day of?

[Dr. Xiaosong Meng]
This starts with the prep process. It's a pretty aggressive prep because we really want to clean up the colon, we want to decrease bowel motion because one of the side effects of bowel motion is it introduces noise and motion into your MRI thermometry, so they get a MiraLAX prep, almost like a colonoscopy prep. Clear liquids before the procedure for a day, sometimes two days. They'll get enema night before, they'll get a enema prior to the procedure in preop. This we'll work as best as we can attempt to get them as cleaned out as possible.

They'll get glucagon to decrease rectal wall motion and bowel motion during the treatment. They'll get those twice. I spend a good amount of time with these guys before the procedure to be like, these are our side effects we're going to talk about. Because I found that if I don't prep them enough, they'll come back and be like, I'm more miserable. It generates a lot of phone calls to my office, so I try to at least prep them ahead of time of what they're going to find. We've treated about a little over 120 patients so far now. I think 10 of them are salvage, the rest of them are primary.

The number one complaint I get is my semen volume is less. That's my first thing under consent. You will have much less semen volume or dry ejaculate after this procedure. Despite sometimes our efforts to spare, it's amazing with MRI, you can see the ejaculatory ducts and we'll try to spare them sometimes when it's appropriate. I haven't found a great correlation to semen volume, whether we spare the ejaculatory ducts or not.

Then I talk about urinary frequency, urgency, symptoms. A lot of these guys will have urgency incontinence in the first four to six weeks just from the irritation of the bladder and the prostate, we're causing a good amount of swelling, but I rarely see stress incontinence. I think stress incontinence, I'd put it at probably 1% or 2 %, but mainly urgency incontinence, certainly within the first few weeks that generally gets better. Then we talk about effects on erections.

The data from TACK, from a lot of our guys, one month is worse erectile function they're going to get, and then it's a slow, gradual improvement over the next three to six months to a year. Some of these guys are pretty aggressive on penile rehab when I see them, if they're not having good erectile function, trying to keep blood flow going to the penis as best as we can. Then I'll talk about small risk of retention. We've had some patients with going to retention, especially if they've had larger prostates, older bladders, more distended bladders. Then all the risk of anytime we operate, there's a small risk for infection.

[Dr. Aditya Bagrodia]
Do you guys use antibiotics?

[Dr. Xiaosong Meng]
We do. We give them usually ceftriaxone.

[Dr. Aditya Bagrodia]
In a standard patient, typically, how long is the catheter staying in?

[Dr. Xiaosong Meng]
The shortest is probably five days. That's truly like a focal, maybe a quadrant or a quarter of the prostate, to about two weeks if we're doing a full near whole-gland ablation.

[Dr. Aditya Bagrodia]
Then, of course cancer control. How do you counsel them on-- We talked about urine impact, sexual function impact, including ejaculate components. Then here's what you can expect in terms of being cured of your cancer. What does that conversation look like?

[Dr. Xiaosong Meng]
I usually start off and say, this is more experimental compared to surgery radiation. We don't have good long-term data, but we do have data from all those HIFU trials, all those cryo trials, and we can extrapolate. If we're doing, I think, true focal, I usually quote about 20%, 25% chance of recurrence. Some of this will be marginal recurrence, some will be contralateral prostate recurrence. The four-year outcomes from the TACK trial, this was whole-gland, but it was a single pass. A little bit different from how we do it now.

I think Daniel and I have learned along the way that as the prostate swells, if you don't count for that swelling when you're doing your treatment, you can leave marginal recurrences. In the TACK trial, they were not allowed to do more than one pass. I certainly think by doing more than one pass, we were improving our cancer outcomes. In the TACK trial, four years, 16% underwent additional treatment. I'll usually counsel them that if we do whole-gland, I would expect the rates of recurrence to go down, but I don't have great data to back that up yet because we're still doing our long-term data analysis, but if we're doing truly focal, I think a quarter is not unreasonable to quote them.

[Dr. Aditya Bagrodia]
Are you ever prophylactically putting supra pubic tubes in for patients that have an elevated PVR, things along those lines?

[Dr. Xiaosong Meng]
We haven't. I know in the TACK trial, everyone got a super pubic tube. We might want to start-- I was going to talk to Daniel about that for some of these guys, especially for the ones that have larger prostates. We have to leave catheter in for a while or they may have to go back in at two weeks. Maybe we should consider a supra pubic tube prophylactically, but for the most part, most of these guys-- I've actually had guys start CIC at two weeks without significant issues.

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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