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New kids on the block: MRI guided transrectal focused US, TULSA, focal laser ablation, histotripsy – a comprehensive review

Prostate Cancer and Prostatic Diseases (2025)Cite this article

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Abstract

Introduction

Prostate cancer (PCa) management poses challenges due to treatment-related morbidities associated with conventional therapies. Focal therapy (FT) is emerging as a promising alternative for intermediate-risk PCa, aiming to selectively target localized cancerous lesions while preserving healthy tissue. This review explores emerging FT modalities for PCa treatment, focusing on transrectal MRI-guided focused ultrasound surgery (MRgFUS), transurethral ultrasound ablation (TULSA), focal laser ablation (FLA), and histotripsy.

Methods

A comprehensive literature search was conducted to identify studies and clinical trials related to FT. Relevant articles were selected and data were synthesized to provide insights into the efficacy and feasibility of MRgFUS, TULSA, FLA, and histotripsy for FT.

Results

MRgFUS utilizes transrectal high-intensity focused ultrasound under MRI guidance to selectively ablate cancerous tissue, demonstrating positive outcomes in oncologic control and preservation of urinary and sexual function. TULSA employs transurethral delivery of high-intensity ultrasound energy under MRI guidance, showing promising results for whole gland treatment. FLA benefits from precise ablation, indicating effectiveness in tumor destruction while preserving quality-of-life. Histotripsy, a mechanical ablation method, exhibits promise by inducing tissue fractionation through bubble activity, offering advantages such as tissue selectivity and real-time treatment monitoring.

Conclusion

Emerging FT modalities present promising alternatives for the management of localized PCa, offering personalized treatment. Further research and clinical trials are warranted to establish the long-term efficacy of these techniques in PCa management.

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Fig. 1: Imaging findings of a 67-year-old patient with biopsy-proven Gleason 7 (3 + 4) prostate cancer treated by transrectal MRgFUS.
Fig. 2: A 69 year-old man with PSA 6.4 ng/ml and biopsy-proven GG2 prostate cancer in a PIRADS 4 lesion at the left mid-gland and GG1 cancer bilaterally was treated with whole gland TULSA.
Fig. 3: Imaging findings of a 59-year-old patient with biopsy-proven Gleason 7 (3 + 4) prostate cancer treated by transperineal MRgFLA.
Fig. 4: Ex vivo human prostate cancer tissue treated with boiling histotripsy.

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Author notes

  1. These authors contributed equally: Sangeet Ghai, Tiffany T. Ni

Authors and Affiliations

  1. Joint Department of Medical Imaging, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON, Canada

    Sangeet Ghai & Tiffany T. Ni

  2. James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Christian P. Pavlovich

  3. Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands

    Jurgen J. Futterer

  4. Department of Urology, University of Washington School of Medicine, Seattle, WA, USA

    George R. Schade

  5. Department of Surgery, Division of Urology, McGill University, Montreal, QC, Canada

    Rafael Sanchez-Salas

  6. Department of Radiology, Clinique de l’Alma, 75007, Paris, France

    Francois Cornud

  7. Department of Surgery, Section of Urology, University of Chicago, Chicago, IL, USA

    Scott Eggener

  8. Halo Diagnostics, Indian Wells, CA, USA

    John F. Feller

  9. Department of Urology, University of Michigan, Ann Arbor, MI, USA

    Arvin K. George

  10. Department of Urology, University Hospital, Lille, France

    Arnauld Villers

  11. Department of Urology, Istanbul Medipol University, Istanbul, Turkey

    Jean de la Rosette

  12. Bashkir State Medical University, Ufa, Russia

    Jean de la Rosette

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Contributions

SG conceived the study, and TN and SG wrote the initial manuscript draft and prepared the manuscript revisions. CP, JF, GS, RS, FC, SE, JF, AG, AV, and JR provided expert feedback and revisions on the manuscript content.

Corresponding author

Correspondence to Sangeet Ghai.

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Competing interests

SG served as Principal Investigator for Phase I and Phase II studies assessing MRgFUS sponsored by Insightec Ltd. GS currently serves as a consultant to EDAP Technomed Inc., an advisor to Immunity Bio, owns intellectual property licensed to Petal Surgical, and his work has been funded by the NIH (NIH R01DK119310 and R01CA258581) and American Cancer Society (RSG2117101). SE previously served as a member of the medical advisory board for Profound Medical approximately from the years 2016-2020. All other co-authors declare no potential competing interests.

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Ghai, S., Ni, T.T., Pavlovich, C.P. et al. New kids on the block: MRI guided transrectal focused US, TULSA, focal laser ablation, histotripsy – a comprehensive review. Prostate Cancer Prostatic Dis (2025). https://doi.org/10.1038/s41391-025-00956-x

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