To preface my comments, I am a prostate cancer patient, not a medical professional who treats prostate cancer. I am passing on my personal experience as I navigate the diagnostic and treatment decision-making process. I am 74. My PSA is 5.6. My mpMRI displayed 2 PIRAD 4 lesions. My fusion-guided biopsy yielded 6 3/3 cores and 1 3/4 core (< 10% pattern 4). My dx was grade 2-favorable PCa in December of 2024. I am in reasonably good health and walk 3-5 miles/day. I identified my QOL priorities as (1) avoiding diapers, (2) minimizing grade 3 toxicity reactions to PCa treatment, (3) minimizing the risk of postoperative cognitive dysfunction that can occur in older adults (over 65) with increasing frequency with age after general anesthesia and (4) maximizing my time with my wife of 54 years. For those reasons, I investigated TULSA.

For those considering TULSA, I just had a consult at Mayo, Rochester, and heard that TULSA is not the best option for everyone. Unfortunately, this includes me, so it might be helpful to others to pass along my notes.

As I understand it, some specific criteria make TULSA an excellent option for focal treatment of PCa:
-the absence of any electrical or metallic implant
-PCa diagnosis of grade 1 or grade 2- favorable;
-clearly visible lesion(s) on mpMRI, preferably unilateral;
-absence of visible indication of a lesion that might approach the prostate capsule or seminal vesicle
-prostate size no larger than 5 cm (superior-inferior) and 6 cm (axial);
-lesions less than 2.9 cm from the urethral center to allow for an external margin around visible lesions;
-absence of prostate calcifications that interfere with ultrasound ablation;
-absence of pre-existing urethral stricture or stenosis;
-patient understanding/acceptance that PCa is a focal disease that may occur at any time in prostate tissue that remains;
-patient understanding/acceptance that post-treatment surveillance criteria for focal ablation are less definitive than surveillance criteria for RP or RT;
-patient understanding/acceptance that biochemical reoccurrence may occur and may result in an upgrading of PCa diagnosis and recommended treatment.

In my particular circumstance, the prostate lesions were on each side of the gland, which has significant calcifications. As luck would have it, both PIRAD 4 lesions were 3/3. The 3/4 core was not visible on the mpMRI. They need to see it on the image to know where to deliver the focal treatment.

I did my best to take accurate notes. If someone finds I've misunderstood the information, please correct it as soon as possible for other's benefit. I hope this may be helpful to others. I'm off to consider other options. The world is full of opportunity and good people!