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Fung KFK, Cazzato RL, Tricard T, Marini PDE, Bertucci G, Autrusseau PA, Koch G, Weiss J, Garnon J, Lang H, Gangi A. MR-Guided Transurethral Ultrasound Ablation (TULSA)-An Emerging Minimally Invasive Treatment Option for Localised Prostate Cancer. Cardiovasc Intervent Radiol 2024; 47:689-701. [PMID: 38491163 DOI: 10.1007/s00270-024-03696-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024]
Abstract
The optimal treatment strategy for men with localised prostatic cancer of low and intermediate risk is an actively evolving field. It is important to strike a balance between maximal oncological control and minimal treatment-related complications, which helps preserve the patients' quality of life. MR-guided transurethral ultrasound ablation (TULSA) has emerged as a minimally invasive treatment option for this group of patients. This article aims to provide of a background on TULSA technology, a step-by-step procedural guide of MR-guided TULSA and to summarise the current evidence of TULSA in management of localised prostatic cancer, as well as other potential indications.
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Affiliation(s)
- Kin Fen Kevin Fung
- Department of Radiology, University of Hong Kong, Hong Kong, Hong Kong.
- Department of Radiology, Hong Kong Children's Hospital, Hong Kong, Hong Kong.
| | - Roberto Luigi Cazzato
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
| | - Thibault Tricard
- Department of Urology, University Hospital Strasbourg, Strasbourg, France
| | - Pierre D E Marini
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
| | - Gregory Bertucci
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
| | | | - Guillaume Koch
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
- Department of Human Anatomy, University of Strasbourg, Strasbourg, France
| | - Julia Weiss
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
| | - Julien Garnon
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
| | - Hervé Lang
- Department of Urology, University Hospital Strasbourg, Strasbourg, France
| | - Afshin Gangi
- Department of Interventional Radiology, University Hospital Strasbourg, Strasbourg, France
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Peters I, Hensen B, Glandorf J, Gutberlet M, Dohna M, Struckmann S, Kuczyk MA, Wacker F, Hellms S. First experiences using transurethral ultrasound ablation (TULSA) as a promising focal approach to treat localized prostate cancer: a monocentric study. BMC Urol 2023; 23:142. [PMID: 37644453 PMCID: PMC10464407 DOI: 10.1186/s12894-023-01306-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 08/01/2023] [Indexed: 08/31/2023] Open
Abstract
PURPOSE To share our experience using transurethral ultrasound ablation (TULSA) treatment for focal therapy of localized prostate cancer (PCa). MATERIALS AND METHODS Between 10/2019 and 06/2021 TULSA treatment for localized PCa was performed in 22 men (mean age: 67 ± 7 years, mean initial PSA: 6.8 ± 2.1 ng/ml, ISUP 1 in n = 6, ISUP 2 in n = 14 and 2 patients with recurrence after previous radiotherapy). Patients were selected by an interdisciplinary team, taking clinical parameters, histopathology from targeted or systematic biopsies, mpMRI and patients preferences into consideration. Patients were thoroughly informed about alternative treatment options and that TULSA is an individual treatment approach. High-intensity ultrasound was applied using an ablation device placed in the prostatic urethra. Heat-development within the prostatic tissue was monitored using MR-thermometry. Challenges during the ablation procedure and follow-up of oncologic and functional outcome of at least 12 months after TULSA treatment were documented. RESULTS No major adverse events were documented. In the 12 month follow-up period, no significant changes of urinary continence, irritative/obstructive voiding symptoms, bowel irritation or hormonal symptoms were reported according to the Expanded Prostate Cancer Index Composite (EPIC) score. Erectile function was significantly impaired 3-6 months (p < 0.01) and 9-12 months (p < 0.05) after TULSA. PSA values significantly decreased after therapy (2.1 ± 1.8 vs. 6.8 ± 2.1 ng/ml, p < 0.001). PCa recurrence rate was 23% (5/22 patients). CONCLUSION Establishment of TULSA in clinical routine was unproblematic, short-term outcome seems to be encouraging. The risk of erectile function impairment requires elaborate information of the patient.
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Affiliation(s)
- Inga Peters
- Clinic for Urology, Krankenhaus Nordwest, Steinbacher Hohl 2-26, 60488, Frankfurt, Germany
- Department of Urology and Urologic Oncology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Bennet Hensen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Julian Glandorf
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Marcel Gutberlet
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Martha Dohna
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Steffen Struckmann
- Department of Urology and Urologic Oncology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Markus Antonius Kuczyk
- Department of Urology and Urologic Oncology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Frank Wacker
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany
| | - Susanne Hellms
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl- Neuberg Str. 1, 30625, Hannover, Germany.
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Anttinen M, Blanco Sequeiros R, Boström PJ, Taimen P. Evolving imaging methods of prostate cancer and the emergence of magnetic resonance imaging guided ablation techniques. Front Oncol 2022; 12:1043688. [DOI: 10.3389/fonc.2022.1043688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
Established therapies for prostate cancer (PCa), surgery and radiotherapy, treat the entire gland regardless of the location of the cancerous lesion within the prostate. Although effective, these methods include a significant risk of worsening genitourinary outcomes. Targeted image-guided cancer therapy has gained acceptance through improved PCa detection, localization, and characterization by magnetic resonance imaging (MRI). Minimally-invasive ablative techniques aim to achieve comparable oncological outcomes to radical treatment while preserving genitourinary function. Transurethral ultrasound ablation (TULSA) and next-generation transrectal high-intensity focused ultrasound (HIFU) utilize MRI guidance to thermally ablate prostate tissue under real-time MRI monitoring and active temperature feedback control. Previous trials performed by our group and others, including a large multicenter study in men with localized favorable-risk disease, have demonstrated that TULSA provides effective prostate ablation with a favorable safety profile and low impact on quality of life. Recently, MRI-guided HIFU focal therapy was also shown as a safe and effective treatment of intermediate-risk PCa. Here we review the current literature on ablative techniques in the treatment of localized PCa with a focus on TULSA and HIFU methods.
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The role of surgery for loco-regional and advanced urological cancers. Curr Opin Urol 2022; 32:634-642. [PMID: 36101519 DOI: 10.1097/mou.0000000000001036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a general misconception that surgery is the antithesis of palliation. However, symptom mitigation, the basic tenet of palliative interventions, can be achieved by invasive procedures. Surgical care, thus, plays an important role in palliative oncology, alongside radiation and systemic therapy. There is global movement to improve palliation in oncology, and thus it is timely to evaluate the role of surgical interventions can play in this setting. RECENT FINDINGS Many of the surgical interventions done with palliative intent were first established as curative options. Most studies looked at interventions for local control of primary tumour including extirpative surgeries, while some studies studied pain relief for bone metastases. Results show that patients have an acceptable survival outcome and complication rate comparable to those done in the curative setting. However, not all studies report functional outcomes and symptom-relief consistently, highlighting an unmet need. SUMMARY More studies are needed to further define the role of surgery in palliative care. Randomized controlled trials studying surgical intervention in the palliative setting will be challenging because of lack of equipoise, inherent bias in patient and disease characteristics in those who undergo surgery. Nonetheless, studies should endeavour to study symptom-free survival and PROMs as meaningful endpoints of interventions performed in a palliative setting rather than solely focus on hard oncological endpoints of survival.
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Dora C, Clarke GM, Frey G, Sella D. Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer: A Systematic Review. J Endourol 2022; 36:841-854. [PMID: 35029127 PMCID: PMC9231661 DOI: 10.1089/end.2021.0866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: MRI-guided transurethral ultrasound ablation (TULSA) uses real-time MR thermometry feedback to target prostate disease. We systematically review the literature to synthesize efficacy, functional, and safety outcomes and assess the influence of planned ablation fraction on outcome. Materials and Methods: PubMed, Embase, and the Cochrane Library were searched from inception to June 2021 following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting at least one efficacy, functional, or safety outcome after a single TULSA treatment were included. The relationship of freedom from salvage treatment and potency preservation with planned ablation volume was modeled. Results: Two hundred twenty-four patients were treated in 10 studies with up to a 5-year follow-up, mainly for primary localized prostate cancer (PCa) plus smaller cohorts with recurrent PCa, and locally advanced PCa (LAPC). The prostate-specific antigen decline from baseline up to 2 years, including focal to whole-gland ablation plans, was 54% to 97%. The rate of salvage treatment after one TULSA treatment for primary PCa was 7% to 17%. Continence and potency preservation were from 92% to 100% and from 75% to 98%. Urinary symptoms were stable in men with good voiding function at baseline, and 85% of men with concurrent PCa and lower urinary tract symptoms met the criteria for improvement. Symptom relief in a small cohort of men with LAPC was observed. Grade III adverse events were incurred by 13/224 men (6%), with no rectal injury/fistula or Grade IV complication. The planned ablation fraction was linearly related to salvage-free survival. The relationship between potency preservation and planned ablation fraction followed a sigmoid curve. Conclusions: As an alternative to conventional treatments, TULSA is safe and effective for prostate tissue ablation in men with primary PCa. There is also evidence that TULSA delivers effective relief of urinary symptoms while treating PCa in a single, low-morbidity procedure. The likelihood of freedom from additional treatment or potency preservation is associated with the planned ablation fraction.
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Affiliation(s)
- Chandler Dora
- Department of Urology, Mayo Clinic Florida, Jacksonville, Florida, USA.,Address correspondence to: Chandler Dora, MD, Department of Urology, Mayo Clinic Jacksonville, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | | | - Gregory Frey
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - David Sella
- Department of Radiology, Mayo Clinic Florida, Jacksonville, Florida, USA
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MR Imaging in Real Time Guiding of Therapies in Prostate Cancer. Life (Basel) 2022; 12:life12020302. [PMID: 35207589 PMCID: PMC8878909 DOI: 10.3390/life12020302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/31/2022] [Accepted: 02/11/2022] [Indexed: 11/22/2022] Open
Abstract
Magnetic resonance imaging (MRI)-guided therapy for prostate cancer (PCa) aims to reduce the treatment-associated comorbidity of existing radical treatment, including radical prostatectomy and radiotherapy. Although active surveillance has been used as a conservative method to reduce overtreatment, there is a growing demand for less morbidity and personalized (focal) treatment. The development of multiparametric MRI was of real importance in improving the detection, localization and staging of PCa. Moreover, MRI has been useful for lesion targeting within the prostate, as it is used in the guidance of prostate biopsies, by means of cognitive registration, MRI-ultrasound fusion guidance or direct in-bore MRI-guidance. With regard to PCa therapies, MRI is used for precise probe placement into the lesion and to accurately monitor the treatment in real-time. Moreover, advances in MR-compatible thermal ablation allow for noninvasive real-time temperature mapping during treatment. In this review, we present an overview of the current status of MRI-guided therapies in PCa, focusing on cryoablation, focal laser ablation, high intensity focused ultrasound and transurethral ultrasound ablation. We explain the important role of MRI in the evaluation of the completeness of the ablation and during follow-up. Finally, we will discuss the challenges and future development inherent to these new technologies.
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Viitala A, Anttinen M, Wright C, Virtanen I, Mäkelä P, Hovinen T, Sainio T, Saunavaara J, Taimen P, Blanco Sequeiros R, Boström PJ. Magnetic resonance imaging-guided transurethral ultrasound ablation for benign prostatic hyperplasia: 12-month clinical outcomes of a phase I study. BJU Int 2021; 129:208-216. [PMID: 34161649 DOI: 10.1111/bju.15523] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/27/2021] [Accepted: 06/14/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To investigate the safety and feasibility of magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) for the treatment of benign prostatic obstruction (BPO). PATIENTS AND METHODS An investigator-initiated, prospective, registered (NCT03350529), phase I study enrolled men with lower urinary tract symptoms due to benign prostatic hyperplasia in need of surgical intervention. Patients were followed for 12 months after TULSA. Uroflowmetry, prostate-specific antigen (PSA) level, and a comprehensive set of functional questionnaires including the Expanded Prostate cancer Index Composite-26, International Prostate Symptom Score (IPSS) and five-item version of the International Index of Erectile Function were obtained at baseline and every 3 months afterwards. MRI was obtained at baseline, and at 3 and 12 months after TULSA. Medication use before and after TULSA were recorded. Adverse events (AEs) were reported using the Clavien-Dindo classification. RESULTS A total of 10 men underwent TULSA with no severe AEs encountered. The baseline median (interquartile range [IQR]) age and prostate volume were 68 (63-72) years and 53 (45-66) mL, respectively. At baseline, six patients were moderately symptomatic and four patients severely symptomatic. Nine patients at baseline were on BPO medication. The median (IQR) improvement in the IPSS was 82%, from 17.5 (15.3-23.0) at baseline to 4.0 (2.3-6.3) at 12 months. Similarly, the median maximum urinary flow rate improved by 101%, from a median (IQR) of 12.4 (8.8-17.6) mL/s at baseline to 21.8 (17.6-26.5) mL/s at 12 months. Improvements were already seen at 3 months. The median prostate volume and PSA reduction at 12 months were 33% and 48%, respectively. There were no changes in continence, sexual, erectile or bowel functions. At 12 months, five out of six men with normal ejaculatory function before TULSA reported normal antegrade ejaculations. All patients taking BPO medication before TULSA discontinued medication after TULSA. CONCLUSION TULSA appears to be a safe and effective treatment for BPO, with promising 12-month follow-up outcomes. Further studies with larger cohorts are needed to confirm the observed results.
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Affiliation(s)
- Antti Viitala
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland.,Department of Diagnostic Radiology, University of Turku, Turku University Hospital, Turku, Finland.,FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland
| | - Mikael Anttinen
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland.,FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland
| | - Cameron Wright
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland.,Department of Diagnostic Radiology, University of Turku, Turku University Hospital, Turku, Finland
| | - Ilari Virtanen
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland
| | - Pietari Mäkelä
- Department of Diagnostic Radiology, University of Turku, Turku University Hospital, Turku, Finland.,FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland
| | - Topi Hovinen
- Research Programs Unit, Stem Cells and Metabolism, University of Helsinki, Helsinki, Finland
| | - Teija Sainio
- FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland.,Department of Medical Physics and Nuclear Medicine, University of Turku, Turku University Hospital, Turku, Finland
| | - Jani Saunavaara
- FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland.,Department of Medical Physics and Nuclear Medicine, University of Turku, Turku University Hospital, Turku, Finland
| | - Pekka Taimen
- FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland.,Department of Pathology, Institute of Biomedicine, University of Turku, Turku University Hospital, Turku, Finland
| | - Roberto Blanco Sequeiros
- Department of Diagnostic Radiology, University of Turku, Turku University Hospital, Turku, Finland.,FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland
| | - Peter J Boström
- Department of Urology, University of Turku, Turku University Hospital, Turku, Finland.,FICAN West Cancer Centre, University of Turku, Turku University Hospital, Turku, Finland
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