TULSA (Transurethral Ultrasound Ablation)
Featured Experts
April 17, 2026
TULSA (transurethral ultrasound ablation), a treatment option for people with prostate cancer, has fewer side effects than some other procedures.
Key Points
- TULSA is a new prostate cancer treatment that helps patients maintain quality of life with a lower risk of side effects than other treatments.
- Patients with an intermediate risk of their cancer spreading may be good candidates for the procedure.
- Johns Hopkins is the first in the Greater Washington and Baltimore region to perform the procedure, and also took part in foundational research.
Urologic surgeon Arvin George, urologic oncologist Christian Pavlovich and radiologist Katarzyna Macura provide an overview of a new treatment for prostate cancer.
What is TULSA?
Transurethral ultrasound ablation, or TULSA, is an outpatient, MRI-guided procedure in which cancerous prostate tissue is destroyed with heat energy, or ablated, using high-intensity ultrasound waves. It is designed to spare nearby nerves responsible for sexual function and urinary continence.
“By using this imaging-based approach, we apply precision into planning the treatment, targeting the cancer and preserving critical structures to optimize functional outcomes,” says radiologist Katarzyna Macura.
TULSA is a form of focal therapy, a kind of treatment that targets small and localized tumors while sparing the surrounding tissue, although it can also treat large areas of the prostate if necessary.
How is TULSA performed?
TULSA is performed in the following steps:
- Patients are placed under general anesthesia so they are still for the procedure, which allows doctors to precisely target the cancer.
- With the patient asleep, a urologic surgeon inserts a thin device called an ultrasound applicator through the urethra, and a separate cooling device into the rectum.
- The patient is then placed in the MRI machine. With MRI guidance, the surgeon can adjust the applicator and make sure the cooling device is in the right place as well.
- The applicator beams out waves of high-intensity ultrasound to the prostate, rotating as needed to target the necessary tissue.
- Throughout the procedure, there is active cooling of the urethra and rectum to avoid damaging tissue in those areas, and doctors use magnetic resonance thermometry, which allows for real-time temperature monitoring of the prostate, urethra and rectum.
“Because the patient is on the MRI table, they can have a diagnostic MRI scan post-procedure using a contrast injection to determine whether we treated all the areas that we planned on treating,” says urologic surgeon Arvin George. “You have multiple layers of feedback.”
The procedure is performed through a transurethral device, so no incision is made, and there is minimal to no blood loss during TULSA.
Who can benefit from TULSA?
Patients whose cancer is confined to the prostate, with an intermediate risk of it spreading (a Gleason score of 7), are the best candidates for TULSA.
Who should avoid TULSA?
Patients with calcium deposits, which can form naturally in the prostate and are usually harmless, should not get TULSA, as the deposits can redirect the ultrasound waves and potentially damage surrounding tissue. A CT scan is typically used to assess patients for prostatic calcifications.
What are possible side effects with TULSA?
While rare and minimized because important nerves can be avoided, possible side effects include:
- Pain or discomfort in the area of ablation
- Erectile dysfunction (ED)
- Urethral stricture (scarring of the urethra)
- Urinary incontinence
- Blood in urine
- Urinary tract infection
In clinical trials, 98% of patients reported preservation of erectile function and urinary continence at one to two years after treatment.
“There were very few patients who had significant long-term side effects,” says urologic oncologist Christian Pavlovich. “Most patients [who receive other treatments] have at least transient ED and urinary incontinence — either of which can persist in some patients — but after prostate ablation, we didn’t see much of either. There were very few long-term impacts noted in the major TULSA trials because you can confine the ablation to the prostate itself.”
How does TULSA compare to other prostate cancer treatments?
Cancer cells in the prostate can also be frozen to cut off their blood supply via cryotherapy or ablated with heat energy using high-intensity focused ultrasound (HIFU). Prostate cancer can also be treated with radiation or by surgical removal of the prostate.
| Procedure | Benefits | Other Factors | |
|---|---|---|---|
| TULSA | Prostate tissue is burned, or ablated, using high-intensity ultrasound waves. | Precisely targets cancer. Designed to spare nearby nerves responsible for sexual function and structures involved in urinary continence. |
May not be as effective at stopping cancer from growing and spreading as radiation and radical prostatectomy. Can be offered as a retreatment method for patients who develop local recurrence. |
| Radical Prostatectomy | Robotic surgery removes the entire prostate. | The goal of removing the prostate is to remove the cancer when it is confined to the prostate. | Possible complications include urinary incontinence, leakage or dribbling; erectile dysfunction; and sterility. |
| Cryotherapy: Used preferentially to treat cancer in front of prostate. | Needle is inserted through the skin under the scrotum, and a warming catheter is placed in the urethra to keep is from freezing. | Minimally invasive. Can serve as an alternative to radiation or surgery. |
Unlike TULSA, the risk of lasting erectile dysfunction can be very high depending on treatment plan. Not able to follow ablation in real time as precisely as TULSA. |
| HIFU: used preferentially for prostate cancer close to the rectum. | Ultrasound waves are delivered via a transducer in the rectum. |
Noninvasive. Aims to target cancer and spare surrounding tissue. |
Not able to treat targets as large as TULSA can as effectively. |
| Radiation | Treatment can be delivered through implanted radioactive seeds via external photon or proton beams. | Can treat prostate cancer at all stages. Can be used to treat prostate cancer that has recurred after radical prostatectomy. |
Modern radiation techniques help reduce the likelihood of urinary and bowel problems, though urinary frequency and urgency are typical side effects. Erectile dysfunction rates increase after radiation therapy. |
| Active Surveillance | For lower-grade, slow-growing cancers, doctors may monitor patients until they feel treatment is necessary. | Avoids treatment and treatment-related side effects. | Can work for patients not experiencing significant symptoms and amenable to close monitoring. Maximizes near-term quality of life. |
How do patients decide which treatment to have?
“TULSA is tailored to each individual patient, and every patient is different,” Macura says. “We can monitor the procedure in a way that not only delivers maximum heat to the target, but also minimizes heat distribution to surrounding regions, giving patients the best outcomes.”
As with any cancer treatment, patients are monitored after TULSA, and if the cancer comes back or spreads, they can discuss other treatment options with their doctor.
“This is a very promising tool, and it adds to the variety of resources we have to treat and manage prostate cancer,” George says. “Not every treatment is the right treatment for every patient, and doctors can discuss TULSA with patients and see if they meet all the criteria.”
What is recovery like after TULSA?
Patients go home the same day with a catheter in, which is typically removed within a week or two depending on a variety of factors. Once the catheter is out, patients may resume normal activities. There will be some discomfort during urination, and there may be some passage of blood or small tissue fragments during urination for a period of time. Also, there may be some erectile dysfunction depending on the ablation treatment plan and the ablated area’s proximity to the nerve bundles that control erectile function.
How was TULSA studied?
A multisite clinical trial of 115 men with low- and intermediate-risk prostate cancer — called the TACT trial — demonstrated TULSA’s utility. The trial found:
At One Year of Treatment
- 65% of patients had completely negative biopsies.
- The percentage of patients with clinically significant prostate cancer — cancer that is more aggressive — decreased from 85% before treatment to 20%.
At Five Years of Treatment
- Only one-fifth of men in the trial needed subsequent treatment for recurrent/undertreated prostate cancer. The remainder are being followed with PSA tests by their providers — essentially a modified surveillance program — in case clinically significant cancer were ever to develop, similar to how patients are followed after radical prostatectomy or radiation therapy.
Was Johns Hopkins Medicine part of the clinical trial?
Yes, Johns Hopkins participated in the multisite TACT (TULSA ablation clinical trial), with Pavlovich serving as the site’s principal investigator. He is also site principal investigator for the multisite CAPTAIN (customized ablation of the prostate with the TULSA procedure against radical prostatectomy treatment) trial, an ongoing trial comparing TULSA with robotic prostatectomy (removal of the prostate) in terms of erectile dysfunction, urinary continence and need for additional treatment.
Medically reviewed by Katarzyna Macura, M.D., Ph.D., and Christian Pavlovich, M.D.
