MRI-Guided Ultrasound Ablation Offers a Middle Ground in Prostate Cancer Care

This Clinician’s View is written by AdventHealth Waterman urologist Michael Fountain, DO.

Prostate cancer presents a unique clinical challenge, not because it is always immediately life-threatening, but because it often isn’t.

For men with early-stage disease, decisions about when and how to treat are rarely straightforward. Intervening early may offer disease control but can come with lasting effects on urinary and sexual function. Deferring treatment helps preserve those functions but introduces the psychological burden of living with a known cancer.

This tension reframes the clinical question. It is no longer solely about how to treat the disease, but how to guide a patient through a decision that directly impacts his quality of life.

In my own practice, I’ve always prioritized shared decision-making and individualized care, working with my patients to align treatment strategies with their personal goals and values. This means I start by asking each patient a simple but essential question: What is most important to you?

Prostate Cancer Treatments and Tradeoffs

About one in eight men will be diagnosed with prostate cancer during their lifetime, making it among the most common malignancies affecting men. More than 3.5 million in the United States are currently living with the disease, and the incidence has risen by roughly 3% annually over the past decade. The good news is when detected early, prostate cancer is highly treatable and often curable.

At the same time, our gold standard therapies -- radical prostatectomy and radiation therapy -- come with well-known tradeoffs. For some patients, the risks of urinary incontinence and erectile dysfunction raise a red flag, leading them to delay or even avoid treatment altogether.

For years, that left many men with early-stage disease feeling like they were forced to choose between active surveillance or aggressive intervention. The introduction of transrectal high-intensity focused ultrasound about two decades ago offered an alternative but still came with the same two troublesome side effects.

The challenge remained. How can we effectively control the cancer while preserving quality of life?

In my practice, addressing that gap has led me to incorporate MRI-guided transurethral ultrasound ablation (TULSA) as an additional option for appropriately selected patients. It offers a minimally invasive, incision-free, radiation-free outpatient treatment for localized prostate cancer and can also be used to treat benign prostatic hyperplasia (BPH).

A New Application of a Widely Used Technology

High-intensity focal ultrasound delivered via a transrectal approach has been used to manage prostate cancer for over two decades now, especially internationally. TULSA uses the same technology but through the urethra, which introduces some meaningful safety and control advantages.

The procedure is performed under real-time MRI guidance with robotic assistance. A catheter-based ultrasound applicator is placed within the urethra, allowing directional energy delivery outward into the prostate. This setup enables precise ablation of targeted tissue while actively protecting surrounding structures.

What I like most is that TULSA offers patients a “middle ground” option between active surveillance and radical treatment. It is another tool in our therapeutic toolbox, allowing us to pursue disease control while also reducing the risk of urinary and sexual side effects that many patients fear most. Importantly, TULSA provides flexibility because we can perform whole-gland or partial prostate tissue ablation, and it does not preclude future treatment with surgery or radiation.

How the TULSA Procedure Works

Performed inside an MRI suite, the TULSA procedure typically takes 2-3 hours under general anesthesia. The transurethral applicator contains multiple therapeutic ultrasound elements that rotate to deliver controlled thermal energy, heating tissue to above 55°C to achieve ablation.

MR thermometry allows us to monitor tissue temperature in real time and adjust treatment as needed. We can actively limit heat exposure to critical structures like the sphincter muscles that manage continence and the neurovascular bundles that protect erectile health. Built-in cooling mechanisms also help protect the urethra and rectal wall.

From a surgeon’s perspective, the ability to make intraoperative adjustments with real-time imaging is a significant strength. The system is highly customizable so we can tailor treatment to the patient's prostate size, shape and tumor location, whether we’re treating focally or addressing the entire gland.

At the end of the case, we obtain contrast-enhanced MRI imaging to see the non-viable tissue and validate that the treatment was successful. I’ve found that reviewing those images with patients afterward has been a beneficial part of the care experience because they can literally see what was treated.

Most patients go home the same day and can return to normal activities within a few days. A catheter typically remains in place for 7-14 days.

Personalizing Care -- Patient Selection and Treatment Flexibility

Patient selection for the TULSA procedure is determined on a case-by-case basis. In general, ideal candidates have low- to intermediate-risk disease that is confined to the prostate, and they have a PSA under 20.

One of the first steps we take to assess for candidacy is to perform imaging of the prostate through either transrectal ultrasound or CT. If a patient has significant calcifications within the prostate, then they might not be a candidate for TULSA because the calcifications interfere with ultrasound transmission. Patients should also be relatively healthy and able to undergo general anesthesia.

The transurethral approach also opens new doors for certain subpopulations of patients. We can treat larger glands than we typically would with transrectal approaches. It’s also a reasonable option for patients with prior extensive abdominopelvic surgery, where adhesions or altered anatomy might increase procedural risk with other techniques. Additionally, we can use TULSA for management of symptomatic BPH.

Treating Residual or Relapsed Disease

Another significant benefit of the TULSA procedure is that it does not preclude future treatment with surgery or radiation. This allows patients to keep their options open. If they need future prostate treatment, they can have a repeat TULSA procedure or choose any other type of prostate therapy to address their needs. Additionally, TULSA can be performed on patients who have previously had prostatectomy or radiation therapy and are now experiencing relapsed or residual disease, offering a new treatment pathway for patients who otherwise have limited options.

Improving Quality-of-Life Outcomes

Early and mid-term data have been encouraging. The TULSA-PRO Ablation Clinical Trial (TACT) was a prospective, observational multicenter study of patients with localized prostate cancer that demonstrated effective tissue ablation and PSA levels with low rates of toxicity and residual disease:

• At one year after receiving the TULSA procedure, median prostate volume decreased by 92%, and 85% were free of Grade Group 2 or higher disease.
• At five years, PSA had decreased from 6.3 ng/ml to 0.63 ng/ml. Additionally, 92% recovered pad-free continence and 87% preserved erectile function.

A separate phase II study (NCT03350529) evaluated TULSA for BPH and found 100% maintained urinary control, 94% preserved erectile function and 96% were able to stop taking BPH medication.

Providing Patient-Centered, Whole-Person Care

There is no perfect procedure for prostate cancer. However, by offering a patient options and education, one of those choices will be as close to perfect as possible for that patient when it comes to meeting their needs and expectations for the future.

Some patients with low-grade prostate disease will choose surgery. Others will prefer radiation. What TULSA adds is another evidence-based option for patients who want treatment but are concerned about quality-of-life tradeoffs.

For me, it comes back to making sure patients feel informed, heard and supported in their decision-making. When a patient leaves my office with a plan in hand that genuinely feels right to them, I know I’ve met them where they are. To me, that is the true essence of providing whole-person care.