Treatment for Prostate Cancer: MRI-Guided TULSA-PRO for Prostate Cancer
The world’s first minimally invasive MRI-Guided TULSA-PRO therapy for prostate cancer was carried out at the ALTA Klinik.
The aim of this treatment is to destroy prostate tumors in a minimally invasive manner so as to preserve the proper functioning of the prostate gland. This aim includes, in particular, preserving normal erectile function and avoiding urinary incontinence.
This aim can essentially be achieved with an optimized and less invasive application of high intensity focused ultrasound (HIFU) known as TULSA-PRO.
TULSA stands for Transurethral ULtraSound Ablation.
The term transurethral means “through the urethra.” Ablation means the “removal of bodily tissue” – in this case via the targeted delivery of ultrasonic thermal energy. Focal therapy is therapy applied only to a localized target (e.g. a cancerous lesion) or focal point. MRI stands for magnetic resonance imaging, a superior medical imaging technique that uses strong magnetic fields to produce three dimensional detailed images of anatomical structures without the use of ionizing radiation.
The treatment involves the thermal ablation of malignant or diseased tissue in the prostate via ultrasound beams that deliver thermal energy of up to 86 °C to a point of convergence in the prostate. The treatment area is precisely demarcated in the context of preoperative planning so as to prevent the destruction of healthy prostate tissue and sensitive peri-prostatic structures (e.g. neurovascular bundles). The ultrasonic thermal energy is applied via an applicator that is inserted through the urethra into the prostate. This means that the thermal energy is delivered directly to malignant prostate tissue and not, as in the case of conventionally applied prostate HIFU, through other structures such as the rectal wall.
The organ-sparing TULSA-PRO technique we carry out at the ALTA Klinik is always a matter of precise focal ablation. More specifically, we use a region-targeted approach to restrict the scope of our treatment to cancerous lesions in the prostate plus a safety margin while leaving the remainder of the prostate intact. Depending on the extent of the lesion or lesions, one-quarter (quadrant ablation) or one-half (hemiablation) of the prostate is ablated.
Patient Advantages with TULSA-PRO
The minimally invasive MRI-guided TULSA-PRO procedure offers our patients a range of important advantages:
- The procedure involves the circumscribed destruction of cancerous lesions and not the removal of the entire prostate gland.
- The procedure offers patients a means of avoiding erectile dysfunction.
- The procedure offers patients a means of avoiding urinary incontinence because the external urethral sphincter and the internal urethral sphincter are left intact.
- The procedure offers patients a means of retaining their capacity for natural ejaculation because the urethra, the seminal vesicles and the ejaculatory ducts are left intact.
- The procedure involves no injury to neighboring structures such as the rectum because it is carried out within the prostate gland.
The TULSA-PRO Technique
The TULSA-PRO technique involves the insertion of an ultrasound applicator through the urethra and into the prostate gland. The ultrasound applicator delivers thermal energy in a targeted manner so as to destroy prostate tumors while preserving the proper functioning of the prostate gland.
The ultrasound applicator is outfitted with a linear array of 10 transducers that emit high-intensity ultrasound beams. Each transducer can be individually activated to enable the optimally circumscribed thermal ablation of malignant tissue. For instance, the operator may choose to activate transducers 2, 3, 4 and 5 because their targeting range corresponds to the dimensions of the tumor in question while leaving transducers 1, 6, 7, 8, 9 and 10 idle.
The TULSA-PRO technique is MRI-guided and takes place inside an MRI scanner. The precision planning for the procedure is based on up-to-date MRI scans.
The ultrasonic thermal energy coagulates the tissue in the designated treatment area. The entire procedure can be monitored and controlled via a computer screen in real time.
The ablation treatment in the MRI scanner does not begin until the applicator has reached the optimal position. This position is reached when a given number of transducers on the linear array of transducers are appropriately aligned to effectively target the tumor. Once the transducers are activated, the applicator is rotated to bring about a uniform pattern of thermal ablation.
An integrated cooling system protects the wall of the urethra against thermal injury throughout the ablation procedure. As a precaution, an additional endorectal cooling device is deployed protect the rectal wall.
Advantages of the TULSA-PRO Technique
The illustration below is provided to help explain the advantages of the TULSA-PRO technique.
- The TULSA-PRO procedure enables the targeted destruction of prostate tumors via the application of ultrasonic thermal energy while preserving normal organ function (1). This requires the use of up-to-date MRI scans to precisely demarcate the treatment area in the context of preoperative 3D planning (2). The focus of the planning procedure is to make sure that neither too much prostate tissue nor too little is ablated.
- The TULSA-PRO procedure involves the insertion of an ultrasound applicator through the urethra into the prostate gland (3). This introduces the advantage of direct targeted treatment within the prostate, which effectively reduces the risk of damage to important surrounding anatomy such as the rectum and the urethral sphincters.
- The ultrasound applicator is outfitted with a cooling system to provide continuous protection against thermal injury to the wall of the urethra (4).
- The cooling system also helps to protect neurovascular bundles against the long-term effects of exposure to thermal energy (6).
- In addition to a precise demarcation of the treatment area, it is also necessary to ensure the precise distribution of thermal energy. The TULSA-PRO system enables high-precision planning and intervention, thereby ensuring that the range of the emitted thermal energy extends only as far as the prostate capsule (7). This sort of control is possible with TULSA-PRO because the temperature in the designated treatment zone can be tracked in real time via MR thermometry on a computer monitor and adjusted accordingly throughout the procedure.
- TULSA-PRO enables a uniform pattern of ablation in the designated treatment area inside the prostate (8).
- With no exposure to the thermal energy during the procedure, the remaining portion of the prostate remains intact (9).
With time the tissue that is coagulated during the procedure is removed from the body via the circulatory system.
Patient PSA levels typically drop down into the normal range after the procedure.
Patient Eligibility for TULSA-PRO
There are a number of prerequisites cancer patients need to meet to be eligible for the TULSA-PRO procedure. The most important perquisite relates to the degree of malignancy, or aggressiveness, of the prostate tumors in question, with malignancy being defined in accordance with the internationally applicable Gleason grading system. Any time pathologists diagnose cancer on the basis of an examination of a tissue sample, they will assign the cancer a Gleason score in their pathology report.
The minimally invasive TULSA-PRO procedure can be performed in men whose prostate cancer has been assigned a Gleason score of no higher than 6 (3+3) or 7a (3+4). This corresponds to those men whose tumors exhibit anywhere from a low-grade malignancy to a moderate-grade, but less aggressive malignancy. This malignancy range accounts for around two-thirds of all men who have been diagnosed with prostate cancer.
Additional Prerequisites for TULSA-PRO
In addition to the Gleason score, the following prerequisites also need to be met for the TULSA-PRO procedure:
- The tumor must not exceed a certain size and volume.
- The tumor must be entirely within the prostate, i.e. must not have breached the prostatic capsule and infiltrated the surrounding fatty tissue.
- There must be a reliable basis for assuming that no other significant tumors are present.
- The cancer must not have spread to neighboring structures.
- The must be no signs of metastasis (e.g. lymphatic or bone metastasis)
Preliminary Diagnostic Procedures
- MRI scan:
Multiparametric MRI of the prostate is the basis for the minimally invasive, organ and function-sparing TULSA-PRO procedure. This examination enables your doctor to ascertain the size and disposition of malignant tumors. The examination also provides all of the prostate-related information that is necessary for the TULSA-PRO procedure.
Based on the experience we have gathered over the course of many years, we carry out a special, optimized multiparametric MRI scan of the prostate.
If the MRI scan indicates the presence of suspicious-looking tissue, i.e. an area of interest in the prostate, then it will be necessary to perform a biopsy to determine the suspected tumor’s degree of its malignancy. The biopsy involves removing a tissue sample from the suspicious site in question. Our special MRI-guided prostate biopsy enables us to remove tissue samples precisely from the suspicious sites in question. These tissue samples are then examined by our pathologist. If the examination reveals a tumor with a Gleason score of 6 (3+3) or 7a (3+4), consideration can be given to removing the tumor via the TULSA-PRO procedure.
If all of the relevant criteria are met, the patient will be given the option of organ and function-sparing TULSA-PRO treatment.
Treatment at the ALTA Klinik Using Outside MRI Scans
TULSA-PRO treatment can also be carried out using the results of an outside MRI scan of the prostate so long as the images meet the criteria for planning the minimally invasive TULSA-PRO procedure. In order to make this determination, we will need to see a CD copy of the imaging material along with the radiology report.
If a biopsy has already been performed, we will also need to see a copy of the pathology report.
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