Transurethral Ultrasound Ablation (TULSA) for Intermediate‑Risk Localized Prostate Cancer

Primary Recommendation

The European Association of Urology recommends classifying patients into risk categories based on PSA level, Gleason score, and clinical stage for localized prostate cancer treatment selection 6, 7
Low-risk disease is defined as PSA <10 ng/mL AND Gleason score ≤6 AND clinical stage T1-T2a, and active surveillance is the preferred approach for these patients 6, 7, 8
Intermediate-risk disease is defined as PSA 10-20 ng/mL OR Gleason score 7 OR clinical stage T2b, and radical prostatectomy and radiotherapy are equally effective treatment options 7, 9
High-risk disease is defined as PSA >20 ng/mL OR Gleason score 8-10 OR clinical stage T2c, and external beam radiotherapy combined with ADT is the standard approach 6
Life expectancy is critical, and curative treatment is generally not recommended for patients with life expectancy <10 years 10, 11

Radical prostatectomy is a treatment option for low-risk, intermediate-risk, and high-risk disease 6, 8
External beam radiotherapy is a treatment option for low-risk, intermediate-risk, and high-risk disease, with consideration of neoadjuvant and concurrent ADT for 4-6 months 6, 12
Brachytherapy is a treatment option for low-risk and select intermediate-risk disease patients 8, 9

After radical prostatectomy, salvage radiotherapy to the prostate bed should be initiated early (PSA <0.5 ng/mL) for biochemical recurrence 6
After radiotherapy, early ADT is not routinely recommended unless patients have symptomatic local disease, proven metastases, or PSA doubling time <3 months 6

For metastatic hormone-naïve prostate cancer, continuous ADT plus docetaxel chemotherapy is first-line treatment for patients fit enough to receive it 6, 12
Treatment options for metastatic CRPC include abiraterone or enzalutamide, docetaxel chemotherapy, radium-223, and denosumab or zoledronic acid 12

Overtreatment of low-risk disease can occur, and proper counseling about active surveillance as a safe option is essential 9
Delayed salvage radiotherapy after prostatectomy can reduce its effectiveness, and it is most effective when PSA is <0.5 ng/mL 6
Inadequate biopsy sampling can miss cancer, and a minimum of 10-12 cores should be obtained 6, 9
Ignoring life expectancy can lead to unnecessary curative treatment, which offers minimal benefit when life expectancy is <10 years 10, 11