Transurethral ultrasound ablation (TULSA) for prostate cancer: a systematic review and meta-analysis

Our objective was to synthesise evidence on oncological, functional and safety outcomes of magnetic resonance imaging-guided transurethral ultrasound ablation (TULSA) for primary and recurrent prostate cancer.

MEDLINE, Embase, Web of Science and Scopus were systematically searched from inception to July 2025. The primary outcomes were 12-month biopsy-proven clinically significant prostate cancer (csPCa) recurrence-free survival (RFS) and rates of pad-free continence and preserved erectile function at last follow-up. Secondary outcomes included biochemical recurrence, progression to salvage treatment and rates of adverse effects.

Twelve studies comprising 630 patients were analysed. In total, 563 (89%) patients underwent primary TULSA, 57 (9%) patients underwent salvage TULSA, and 10 (2%) patients had palliative TULSA. Pooled 12-month csPCa RFS was 70% (95% confidence interval [CI] 50-84) for primary TULSA and 80% (95% CI 66-89) for salvage TULSA. Stratifying by ablation fraction, pooled 12-month csPCa RFS was 75% (95% CI 60-86) for whole-gland TULSA, and 71% (95% CI 51-86) for focal TULSA. The proportion of pad-free continence was 90% (95% CI 71-97), and the rate of preservation of erectile function was 81% (95% CI 56-94). Incidence of grade 3 severity adverse events was 6% (95% CI 4-11). There was heterogeneity in multiple outcomes, likely reflecting variation in endpoint definitions, treatment approaches and follow-up protocols among the included studies.

Primary TULSA is a safe treatment modality with a low risk of functional morbidity. However, there is a lack of evidence on long-term oncological control, with modifications of the treatment technique and ablation parameters still being experimental. Fewer data are available for salvage TULSA, where preliminary studies have recorded relatively high rates of incontinence.