Prostate cancer is a slow-growing but nefarious disease. The American Cancer Society estimates that in 2021 alone, more than 248,000 new prostate cancer cases will be diagnosed, making it the most common cancer in men. It also represents more than 13 percent of all cancer cases in the U.S.
Traditional treatment options such as surgery to remove the prostate and radiation therapy are effective at getting rid of tumors. However, for patients with localized, low-risk and some with intermediate-risk prostate cancer, the benefits of removing a tumor are often counterbalanced by the life-altering side effects of treatment. Even in the hands of a skilled surgeon or oncologist, erectile dysfunction and urinary incontinence are possible following prostate cancer surgery.
For some patients who choose active surveillance, which involves closely monitoring the tumor to make sure it isn’t getting worse, the frequent checkups and knowledge that they have cancer can prove stressful.
But now there is another treatment option, and UT Southwestern is one of just a few U.S. centers that offers it.
Transurethral ultrasound ablation (TULSA) is a new outpatient procedure that was approved by the U.S. Food and Drug Administration in 2019 for prostate tissue ablation after the TACT clinical trial. Ablation refers to the destruction of tissues, in this case with heat: no incisions, surgery, or radiation required.
Data from a 2020 study published in The Journal of Urology shows that TULSA can effectively destroy cancerous prostate tissue with reduced side effects and low toxicity. Our data show that TULSA:
- Reduced overall prostate size by more than 80 percent.
- Reduced the telltale cancer sign – levels of the protein prostate specific antigen (PSA) in the blood – by 95 percent.
- Allowed 75 percent of patients to maintain or regain sexual function after treatment.
How TULSA works
TULSA is the new, hipper cousin of HIFU – high-intensity focused ultrasound – which was itself a game-changer in prostate cancer treatment. But unlike HIFU, which also uses ultrasound waves to ablate prostate tissue through the rectum, the directional ultrasound beam originates from the device in the urethra. As such, TULSA reduces the chances of damaging important surrounding organs such as the rectum.
Diagnosis and planning
Prostate cancer is diagnosed after a biopsy of the prostate. MRI imaging identifies any areas of concern and these areas can be targeted for ablation.
At UT Southwestern, we use a 3 Tesla MRI to take images of the prostate. If the images show suspicious lesions, a biopsy aimed at that region usually is warranted. Then, if the biopsy confirms the presence of cancer, we will discuss the pros and cons of all your management options including TULSA.
If men had a biopsy elsewhere then we can review the biopsy results and their prior MRI. If they had not had a prior MRI, we perform one to make sure there are no additional areas of concern that require a biopsy.
If you select TULSA, the procedure begins with taking multiple images of the prostate from front to back, as if we were dividing it vertically into slices. Using these images, we map a region around the cancer. We input that schematic into the TULSA machine as the treatment plan to “teach” it where to ablate for each individual patient, maximizing the chances of controlling the cancer while reducing the likelihood of damaging important structures nearby, such as nerves responsible for the sexual function.
The outpatient procedure is done under general anesthesia in the MRI suite, and the ablation itself usually takes less than an hour. Overall, most procedures are done in two to three hours.
The urologist inserts a slim device into the urethra from the tip of the penis and advances to the prostate. The position of the device is confirmed using MRI. The device emits ultrasound waves that heat the prostate tissue within the pre-mapped area (including the cancer) to 50-60 degrees Celsius (120-140 degrees Fahrenheit) – just hot enough to cause irreversible cell damage, which kills the cancerous cells.
The device also has a system that cools the urethra, protecting it from unintended damage. The temperature in the prostate is monitored in real time to make sure the appropriate tissue is heated and there is no damage to surrounding structures.
TULSA is an outpatient procedure. Recovery has been shown to be relatively easy. Most patients use little to no pain medication, and they say the worst part is having to temporarily use a catheter for a few days after the procedure. This is the same type of catheter used in patients who choose to have surgery. Once the catheter is removed, patients may have a weak urine stream or frequent urination, which should resolve within a few weeks.
Related reading: What we know about your prostate
A closer look at how TULSA treats prostate cancer
UT Southwestern is one of a few centers nationwide offering the novel therapy. (Video courtesy of Profound Medical Corp.)
Eligibility for TULSA
Patients with low- to intermediate-risk prostate tumors – regardless of size – that are less aggressive and have not spread outside the prostate may be eligible for TULSA. Some patients who would be eligible for active surveillance and wish to treat the cancer while attempting to avoid the side effects of surgery might also be eligible for TULSA.
Patients of any age may choose TULSA, and young men may enjoy the most long-term benefits. However, not every patient is eligible. If you can’t get an MRI due to having an implant, or if you can’t have anesthesia, you will not be able to undergo TULSA. Men might not be eligible for TULSA if their cancer has spread beyond the treatable local area, such as outside the prostate. Patients with calcium deposits in certain areas of the prostate may also be ineligible, as these can interfere with treatment.
At UT Southwestern, patients with prostate cancer benefit from the close collaboration between our specialists in urology, oncology, imaging, and genetics. Our coordination, discretion, and multidisciplinary expertise result in easier referrals, more streamlined care, and potentially better outcomes.
While working together, each provider offers you a slightly different perspective that helps you gather the data that will allow you to make an informed decision of what is the best course of action in your case. All your records are in one place and your full care team will have the latest information about your case at the same time.
Follow-up after TULSA
The current follow-up for TULSA is having a post-procedure visit, which can be by video or in person, as well as MRI (at 6-12 months) and periodic PSA level checks during the first year. If the MRI and PSA results are reassuring, PSA checks can be done at least every six months, with MRIs done less frequently. If the results are abnormal, some patients may need a repeat biopsy to look for residual disease.
Preliminary data show that if the cancer does return after TULSA, patients continue to have the option to treat the cancer with surgery, radiation, or repeat TULSA. This is another benefit of TULSA, because doing surgery after radiation can be difficult.
The ease of recovery is among the most impressive elements. There is some initial urinary frequency and weak urine flow that resolves with time. Despite the discomfort related to the catheter that stays in place for a few days, we get messages regularly from patients that recovery is “a walk in the park” and they “didn’t even have to take Tylenol” for pain within days of treatment.
Future of prostate cancer treatment
For some men, removing the entire prostate may no longer be necessary. As we learn more about the disease and how to reliably map it inside the prostate with advanced imaging, opportunities arise to treat the disease at a cancer-focus level rather than the entire prostate.
Today, insurance coverage may vary since this novel therapy is not yet a standard of care. As the procedure becomes more widely known and available, we expect the amount of coverage to increase. Before the procedure, patients can discuss their coverage with our financial counseling team to estimate potential out of pocket costs.
Since the procedure is so new and only a few centers offer it, we do not have long-term data to quote specific outcome trends. We are joining a multicenter registry to collaborate with other institutions that offer TULSA for prostate cancer so we can share in that information as the database grows.
As an academic medical center, it is important for us to be able to offer clinical trials for patients interested in focal therapy for those who might not be eligible for TULSA. We are working toward opening a trial of this nature through the Prostate Cancer Clinical Trials Consortium.
For men with localized, low- and intermediate-risk prostate cancer, eliminating cancerous prostate tissue with TULSA can provide a safe and effective option.
Innovations in prostate cancer care
UT Southwestern specialists from the Simmons Comprehensive Cancer Center delve into some of the latest technology and techniques in this webinar that first aired on May 6, 2021.