BackTable / Urology / Podcast / Transcript #94

Podcast Transcript: TULSA-PRO: A Practical Guide for Setup and Success

with Dr. Daniel Costa and Dr. Xiaosong Meng

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. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) TULSA: A New and Innovative Prostate Cancer Treatment Option

(2) Ideal Candidates for TULSA Treatment

(3) Patient Workup and Treatment Considerations for TULSA Prostate Ablation

(4) Contraindications, Preparations, and Outcomes of TULSA Treatment

(5) Patient Preparation, Side Effects, and Cancer Control

(6) Patient Positioning and Imaging

(7) Procedure Technique: Urethral Applicator, Rectal Cooling Device, and Real-Time Monitoring

(8) Post-Operative Care and Follow-Up

(9) Establishing a TULSA Program: Cross-Specialty Collaboration & MRI Compatibility

(10) Insurance Coverage for TULSA

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[Dr. Aditya Bagrodia]
This is Aditya Bagrodia as your host this week, and I'm very excited to introduce our guests today, Daniel Costa and Xiaosong Meng from UT Southwestern Medical Center. How are you guys doing today?

[Dr. Xiaosong Meng]
We're good. Thank you for having us on, Aditya.

[Dr. Daniel Costa]
Great, Aditya. Thanks for the invitation.

(1) TULSA: A New and Innovative Prostate Cancer Treatment Option

[Dr. Aditya Bagrodia]
I'm really excited to have you on today. When this idea of discussing TULSA came up to me, it was a no-brainer. Daniel and Xiaosong are very thoughtful clinicians, very meticulous, and I know that as they've rolled out this program at UT Southwestern, it's been done exactly like it should, in my opinion. Really, congrats on the work that you've done today treating over 100 patients with TULSA, and really hope to pick your brains on what all lessons learned, starting the program over the last few years. Maybe just to jump on into it, why don't we just have a little introduction into TULSA as a treatment option for patients with prostate cancer?

[Dr. Xiaosong Meng]
TULSA's the new kid on the block. It's only been FDA-approved, I think, since 2019 or so. I think UT studied their program in 2020 and the difference between TULSA and some of the other modalities is it's done in boar, it's done in the MRI magnet, and it's done with ultrasound. Instead of being like HIFU, which is High-Frequency Focused Ultrasound, it's transurethral ultrasound and it's a sheet of ultrasound.

The thing I really like best, and Daniel can probably attest to this, is the amount of feedback you get from your treatment. Every five to six seconds you get MRI thermometry, you can get a really nice view of exactly [00:03:45] where you're heating, where your margins are, where your boundaries are, which I think is different compared to some of the other focal technologies we have out there. We see demand, especially a lot of these guys are engineers, really like technology, and they really like what TULSA represents and the capabilities it represents.

[Dr. Aditya Bagrodia]
Perfect. Daniel, what do you think from your end? How would you just describe this to either a patient or a colleague?

[Dr. Daniel Costa]
I think from a radiologist's perspective, the visual nature of the procedure is extremely appealing. As Xiaosong mentioned, the ability to see in real-time both the anatomy and the temperature throughout the entire prostate is extremely reassuring both for us. I think it's also a concept that the patients have when they visit with us, and you're super intrigued and excited that we are able to do that during the procedure.

[Dr. Aditya Bagrodia]
Xiaosong, if I'm not mistaken, over the course of your training and career, you've been exposed to some of the most frequently used technologies that are out there. It really is an exciting time. We have cryo, we have HIFU, we have irreversible electroporation, focal brachy, focal SBRT, and TULSA as a newer one. In addition to the visualization of your treatments, are there any other theoretical or real advantages that you perceive?

[Dr. Xiaosong Meng]
Yes. That's a good question. During residency at NYU, we did focal cryo. I also saw some HIFUs that NYU was doing. They had both programs. Then here at UT, I've started doing irreversible electroporation on the preserved trial and off-trial, as well as CAPTAIN and with TULSA. I know Neil Desai is one of our rad oncs here, talks about the MRI-LINAC and the HDR brachy program that they do with Dr. Garant. Certainly, I agree, it's a great time to be in prostate cancer. I think this is likely going to change how we treat intermediate-risk prostate cancer in the future with all these different new technologies coming on board.

I think one of the benefits obviously with TULSA is that we're going urethra out. The company's very careful about this in terms of when we're ablating near the rectum, they're very careful about making sure we don't overdraw where we want to ablate. At the moment, out of about 3,000 cases around the world, there's been no recto-urethral fistula this way. Even though I think cryo with the thermometry or the thermal couples, HIFU, the rates are coming down.

I don't think the rates of recto-urethral fistula is, I would say are, 1% or 2% with both these technologies. I think going from urethra out, it certainly gives us some benefit of avoiding the rectum. I also think when you come in, if you have to do a savage procedure, Dr. Wilburn's done two savage procedures post TULSA, the plane is not as horrible as post some of these other focal modalities, because I think we're preserving that posterior plane better.

(2) Ideal Candidates for TULSA Treatment

[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.

(3) Patient Workup and Treatment Considerations for TULSA Prostate Ablation

[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 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.

(4) Contraindications, Preparations, and Outcomes of TULSA Treatment

[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.

(5) Patient Preparation, Side Effects, and Cancer Control

[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.

(6) Patient Positioning and Imaging

[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.

(7) Procedure Technique: Urethral Applicator, Rectal Cooling Device, and Real-Time Monitoring

[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.

(8) Post-Operative Care and Follow-Up

[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.

(9) Establishing a TULSA Program: Cross-Specialty Collaboration & MRI Compatibility

[Dr. Aditya Bagrodia]
When I started here at UC, San Diego, there's this idea of really having a whole suite of options available to patients. Of course, surgery and radiation, as I mentioned, we have HIFU, we have cryo, and we're looking at TULSA and I was like, "Oh, great. I am familiar with this procedure at least through the patients that have been treated at my previous institution in UT Southwestern and started digging into it. The first thing was that none of our MRIs at multiple hospital locations, et cetera, were compatible with the profound technology. Let's maybe run through the nitty gritty. A urologist or a group or a hospital has decided that we're going to commit to this.

What are the 101 side? Maybe I'll just throw it out there, MRI compatibility. Either you've got one that's compatible, or you need to get one that's compatible. Can you comment on that?

[Dr. Daniel Costa]
Yes, certainly a joint effort from the different departments and the hospital administration and does require the desire to work together and the ability to work together. We've talked about this in other instances. I am very comfortable, and it's a great source of joy working with urology and that is to a great extent a result of our collaboration in the targeted biopsy field. I think the targeted biopsy brought radiology and urology together for good. It's a great example of us partnering to advance the field and help the patients. It's a great opportunity to have accountability, to have urologists.

It's a great opportunity to have radiology learning from the feedback that we receive from the biopsies performed by urology and it's a great opportunity for urology to see the added value of imaging in the patients that they manage. I see that as a great opportunity for both departments to work together better than they would do separately. It is a huge building block for any focal therapy program. When it comes to building the focal therapy program, when it comes to the time, let's say, you're considering starting a TULSA program, there is a checklist to go through, and one of them you mentioned the DTA is the MRI compatibility.

The MRI compatibility used to be more an issue at the beginning when the device was just released, but the company continued to work to make their software compatible with other vendors and to different platforms from all the vendors. There are also compatibility issues when it comes to the room. You have to have like a panel that allows you to access the room. These are all things that can be sorted out if there is willingness to put an effort, but it does require some planning. I would say as of today, probably these aren't that much of an issue as they were two or three years ago both because the company has worked to address these compatibility issues but also because it's much more standardized what needs to be done.

I think it's very important that the stakeholders need to understand what they want to accomplish and why they want to embark on such a journey and go over the different technologies that exist out there and why they would choose one or the other or maybe a few of them. I think what we are learning is that there is no perfect focal therapy solution that solves, or that is able to provide great treatment for every single patient. I think as this brainstorm happens, maybe getting to a point where you're able to offer solutions that complement one another or that have the ability to truly expand the patient population that you're able to offer focal therapy would make perfect sense. I would emphasize the importance of that partnership.

As you very well said, I think you can see a TULSA patient journey in three stages. The pre-TULSA assessment that requires a lot of baseline risk stratification, vetting those patients with high-quality imaging, with imaging pathology, concordance review. Then there is the TULSA treatment day where there needs to be expertise in device handling, delineating the area to be treated, accounting for things that we talked about, gland swelling motion to make sure that you're treating the patient properly. Then there is a third stage which is the post-TULSA, it's managing a patient that had a cancer treated plus the knowledge of what are the potential complications that are specific to a TULSA procedure. When we look at those three different stages, I think you can certainly see that we need the expertise from all the stakeholders.

[Dr. Xiaosong Meng]
To echo some of Daniel's points, certainly I think some of the logistical stuff, MRI compatibility, I think the company Profound will come out and do their analysis and they'll let you know what you need or what you don't need. From a programmatic standpoint, I think you not only have urology radiology, you need buy-in from your med oncs, your rad oncs because a lot of times what we've found recently is that, like you said, these patients coming in with high-risk disease or low-risk disease or in rare cases, metastatic disease or asking for TULSA. You need to be able to have the ability to say, "No, you're not a good TULSA candidate, go see my radiation oncology colleague, go see my medical oncology colleague."

As a certain point, we're the gatekeepers that we need to make sure that these patients are getting the appropriate care regardless of where they need to go to get that care. Sometimes it's TULSA and oftentimes it's not TULSA. Sometimes they're better served by radiation, sometimes they're better served by surgery.

(10) Insurance Coverage for TULSA

[Dr. Aditya Bagrodia]
I've had the good fortunate pleasure of observing the close collaboration between radiology and urology at UT Southwestern. It's unique, it's special and I think it's what allows this type of program to be rolled out in a careful and considerate way. Daniel, you mentioned the third aspect of this is commitment from hospital administration. When I think about hospital administration, I'm thinking about dollars and cents here, ballpark. What are we talking about in terms of capital costs to initiate the program and are these procedures now covered by insurance?

[Dr. Daniel Costa]
Yes, so there are lots of nuances to this answer. As of today, there is no billing code for TULSA. If the procedure is done at a hospital, the hospital can bill for C codes and most of our patients are either Medicare patients or a mixture of Medicare plus private payers. The hospital is being reasonably paid for the cost of this procedure. In regards to capital cost, the model that the company right now chose to have is you pay for the disposable kit for each patient so you don't have to buy any equipment upfront, you just pay for the disposable kit.

The lack of a billing code results in suboptimal reimbursement for the professional fees. As of today, the urologist and the radiologist involved are not properly reimbursed for this procedure. If this is in a managed care or Medicare patient, there are facilities that are choosing to have a cash pay-only approach to this and that's a different story. Now, the company is partnering with professional societies to submit an application for CPT code for TULSA and the expectation is that this would be done later this year. By early 2025 is the best-case scenario for us to be able to bill for this from a professional fee standpoint.

[Dr. Aditya Bagrodia]
I think that was a comprehensive answer to what sounds like a complicated ongoing evolving issue. Hey, I think that I've certainly learned a lot about the program, about the details of it. I think it's exciting, I think it's accessible, but it really takes a pretty serious commitment. I would imagine that there's opportunities for proctoring for courses and things along those lines to learn more about this and see if this could be a good fit for an individual's practice or institution. Is that accurate?

[Dr. Xiaosong Meng]
We've certainly hosted a few of the physicians who are interested in since starting the TULSA programs here, I think Profound now has rolled out a few different sites where they're allowed to pose physicians. We haven't had this set up at UT and partly because it's due to conflicts. I'm the PI for the CAPTAIN trial, Daniel is the PI for the care registry, which is the TULSA registry. There are some financial aspects of that, so we don't have UT currently open as a site where patients or physicians can come and learn about it. We can do it through UT Southwestern.

For instance, Aditya, if you wanted to come over, I fill out some paperwork, we can bring you down, spend a day with us in the suite and do procedures. I think they're setting up more formalized ways for them to do that as well.

[Dr. Aditya Bagrodia]
Fantastic. Again, I think that what you guys have been able to do, and maybe just so if you don't mind just a brief word on the CAPTAIN trial.

[Dr. Daniel Costa]
Yes. CAPTAIN trial I think is a really good trial. I don't think we've had any really randomized trials comparing surgery to a focal ablative modality in terms of this is a randomized two-to-one trial, so out of every three patients, two patients get randomized. The whole-gland TULSA, one patient gets randomized to surgery. The trial started in January 2022 and they're looking for about 200 patients. I think we're probably about 20% accrual at the moment. It's multicenter, it's from US and Canadian sites.

I've actually been surprised that the patients who've been agreeing to be randomized, you think that a lot of these patients are like, "I want this or that and these patients have been very generous with their time and give us the ability to randomize them. It's for only intermediate-risk disease patients, so three plus four, four plus three. They have Gleason grade group one, Gleason grade group four, they're not eligible, if they have unfavorable intermediate-risk disease, they need a bone scan or PSMA PET scan as part of the workup, but they get tracked very closely. They have surveys, they do a stretch of penile lathe measurement as part of it comparing surgery risks in TULSA. I think it's a good trial. I really hope that it meets its accrual, and we get some useful data out of it.

[Dr. Aditya Bagrodia]
Amazing. Obviously, that's the alpha they make when it comes to answering these and I think shedding light on not just cancer control, but the functional outcomes is going to be amazing. Congrats for getting that off. That's clearly no small lift there. Hey, I think I could talk about this and pick your brains, but I do want to be respectful of your time, and Daniel, we can start with you just, just parting thoughts about TULSA, the role for it, developing a program as we wrap up here.

[Dr. Daniel Costa]
First, thank you Aditya for the opportunity to share the beginning of our learning curve with our community. We are fortunate to have been exposed to this technology early on. There is still quite a bit to learn about it, and that discovery phase is extremely exciting, a big responsibility and it's great to be able to partner with urology during that exploration. We certainly are committed to responsibly gathering the data that will help us understand what is the long-term outcome of these patients, both quality of life and oncologic speaking. We will be more than eager to share that with our community as well.

It is as I said, not a plug-and-play technology. Something that is, again, both a responsibility to do it well, but also exciting that we can continue to learn as we're doing these treatments.

[Dr. Aditya Bagrodia]
Perfect. Xiaosong, how about from your end?

[Dr. Xiaosong Meng]
I think for me, as a newer faculty member, it's great to be in this area. I think it's a very exciting time to be in this area, whereas we're getting more and more treatments for these guys. I truly believe that it's probably going to change how we treat guys with intermediate-risk disease moving forward, probably in the next 10 or 15 years or so as more of these technologies come on board. I think it's a great technology. I certainly enjoy using this technology. It's not the end-all-be-all for all prostate cancer treatments. Like Daniel said, I think you need complementary technologies for truly building out a programmer, as patients are coming in, you need to be able to treat patients with different modalities based on their anatomy and their characteristics.

I think it's a valuable tool in our armamentarium similar to radiation and surgery and MR-Linac and all these other technologies that are coming on board. It's a matter of directing patients to what we think is best for them. It's really personalizing their cancer treatment in some ways. Daniel and I are certainly very excited about this. Even though we're busy, we're very happy to talk to physicians to feel free to pass along my information if they have questions, if they want to come down take a look at some cases, if they have patients that they have any questions about, feel free to reach out to me or Daniel, I'd be happy to answer those questions.

Certainly, I've learned that these TUSLA patients are willing to travel. We've treated almost-- I don't want to say almost like a quarter of our cohorts probably out from outside of the state of Texas where they're willing to travel for this technology. It's the hot new technology right now and there is certainly a long learning curve for it that we're learning about as we're doing it. Certainly happy to share all that experiences with anyone who's interested.

[Dr. Aditya Bagrodia]
I love it. I think the careful responsible exploration and rollout of any type of new really technology or test or whatever you want to call it, is the mandate here. What I love about the program and Dallas is that I know that's precisely what is taking place. I've certainly sent a couple of patients. Nothing could be easier, personal contact, personal email for not just providers, but patience is provided. Hey, congrats to you all for what you've been able to do there. I think that as we move forward, these early experiences of a blink of an eye will be longitudinal studies, randomized trials, and it's always exciting to be on the front end of practice-changing intervention. Thanks for your time. Wonderful to see you all, and until next time.

[Dr. Xiaosong Meng]
All right. Thanks, Aditya. Great seeing you as well.

[Dr. Daniel Costa]
Thank you, Aditya.

Podcast Contributors

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

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

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 https://www.backtable.com

Disclaimer: The Materials available on BackTable.com 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.