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Approaches to Bladder Drainage After MRI-Guided Transurethral Ultrasound Ablation (TULSA) for Prostate Cancer - Beyond the Abstract

The treatment of low and intermediate-risk prostate cancer remains a controversial subject necessitating that urologists maintain a broad, yet specific knowledge of the complications and outcomes associated with multiple, relatively new treatment options. Burdensome sexual and urinary complications associated with standard treatment options have galvanized providers and their patients to investigate alternative, less morbid treatment options.1–4 In this context, magnetic resonance imaging (MRI)-guided transurethral ultrasound ablation (TULSA) of the prostate was developed as a minimally invasive ablative technology to treat prostate cancer. TULSA uses a linear array of continuously sweeping, high-intensity ultrasound elements to deliver energy through a cystoscopic device using customized, MRI-based treatment planning and thermometry.5,6

While TULSA represents a new, promising technical innovation for prostate cancer treatment, its use is still relatively limited due in part to the significant operational requirements of the treatment (anesthesia, an MRI suite, and one or two treating physicians with radiologic and urologic expertise). In addition, its adoption has been hampered by the lack of long-term data regarding its efficacy, reimbursement issues, and lack of quality data guiding best practices for postoperative management. Like other ablative therapies for the prostate, TULSA necessitates bladder drainage via a catheter for a finite time period to allow for resolution of treatment-related edema and inflammation. Until now, bladder drainage for patients has involved using either an indwelling urethral catheter or a suprapubic tube. Very little was known of notable advantages or disadvantages associated with either technique.

Aiming to guide future practice, our study assessed urinary outcomes and complications following whole-gland TULSA by comparing indwelling urethral catheterization versus a suprapubic tube for bladder drainage. We ascertained that despite a more pronounced rise in lower urinary tract symptoms within one month of surgery in patients receiving a urethral catheter, no significant difference in 6-month urinary outcomes was observed, and both groups reported low rates of urinary incontinence. Rates of infections, strictures, and catheter reinsertion were statistically comparable between groups, despite strictures being about three times more common in the suprapubic tube group.

While our findings are intended to be hypothesis-generating in the setting of a relatively small cohort, these data suggest that suprapubic tube and urethral catheterization are both acceptable options for postoperative urinary management following TULSA, and appear to be associated with similar complication rates despite different side effects profiles. Accordingly, we feel that the use of either drainage strategy is acceptable after TULSA whole-gland prostate ablation, per the surgeon’s discretion.

Written by: Matthew J. Rabinowitz, BS, and Christian P. Pavlovich, MD, Johns Hopkins University School of Medicine, Baltimore, MD

References:

  1. Resnick MJ, Koyama T, Fan KH, et al. Long-term functional outcomes after treatment for localized prostate cancer. N Engl J Med. 2013;368(5):436-445. doi:10.1056/NEJMoa1209978
  2. Boorjian SA, Eastham JA, Graefen M, et al. A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes. Eur Urol. 2012;61(4):664-675. doi:10.1016/j.eururo.2011.11.053
  3. Hu JC, Gu X, Lipsitz SR, et al. Comparative effectiveness of minimally invasive vs open radical prostatectomy. JAMA. 2009;302(14):1557-1564. doi:10.1001/jama.2009.1451
  4. Bass EJ, Ahmed HU. Focal therapy in prostate cancer: A review of seven common controversies. Cancer Treatment Reviews. 2016;51:27-34. doi:10.1016/j.ctrv.2016.07.004
  5. Sundaram KM, Staruch R, Burtnyk M, Lane JS, Penson DF, Arora SS. MR Imaging-Guided Transurethral Ultrasound Ablation of Localized Prostate Cancer: Preliminary Experience from a Single Center in a Prospective, Multi-Center, Single-Arm Clinical Trial. J Vasc Interv Radiol. 2020;31(5):740-746.e4. doi:10.1016/j.jvir.2019.12.802
  6. Klotz L, Pavlovich CP, Chin J, et al. Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Cancer. J Urol. 2021;205(3):769-779. doi:10.1097/JU.0000000000001362

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