It is late, and you have a dozen browser tabs open.
Somewhere between your diagnosis and tonight, the vocabulary changed.
Surgery and radiation, you understood. Now you are reading HIFU, FLA, IRE and TULSA-PRO, and each one says it treats cancer while protecting what you want to keep.
None of them explains how it differs from the others.
This post is meant to be that explanation. We describe each approach plainly, cite the published studies behind the numbers, and include where the alternatives have real strengths. One disclosure first: Integrative Urology offers TULSA-PRO, so that is the option we can speak to most directly. For the others, we are describing mechanism and published results, not ranking them.
TULSA-PRO, HIFU, focal laser ablation, cryoablation and irreversible electroporation (IRE) are all energy-based ablation therapies. They destroy prostate tissue in place rather than removing the gland. They differ in the type of energy (sound, laser, cold or electrical pulses), how it reaches the prostate, and what guides the treatment. Which one fits depends on your tumor's location, grade and size, your prostate anatomy and your priorities. A specialist needs to review your MRI and biopsy to say.
In this article
Each one aims to destroy cancerous tissue while sparing the urethra, nerves and sphincter that affect urinary control and sexual function. Some are used to treat only the area of cancer (focal therapy). Others can treat the whole gland. Several can do either, depending on the device and the treatment plan.
TULSA-PRO (Transurethral Ultrasound Ablation) works from the inside out. A slim ultrasound applicator placed in the urethra delivers directional heat outward into the prostate while you lie in an MRI scanner. Closed-loop MRI thermometry reads tissue temperature in real time, and the system adjusts treatment parameters to match the plan. An endorectal cooling device helps protect the rectum [1]. TULSA-PRO received FDA 510(k) clearance in August 2019 [2].
The pivotal TACT trial enrolled 115 men with low- to intermediate-risk, organ-confined prostate cancer at 13 sites in five countries. Each man received a single whole-gland treatment that spared the prostatic urethra and urinary sphincter [1][5]. At 12 months:
TACT pivotal trial: results at 12 months
At five years, as presented at the 2023 Society of Urologic Oncology meeting [5]
These numbers describe a study population, not what any one man should expect.
High-intensity focused ultrasound (HIFU) also uses sound waves to heat and destroy tissue. The difference is the route. HIFU is typically delivered through the rectum, so the energy passes through the rectal wall to reach the prostate.
UK multicentre study: 625 men treated with focal HIFU, median follow-up 56 months [6]
Failure-free survival meant freedom from radical or systemic therapy, metastases and cancer-specific death.
HIFI study: 3,328 men chose whole-gland or subtotal HIFU or radical prostatectomy [7]
The authors noted that the groups were not randomized and differed in age.
Three HIFU systems are FDA-cleared for prostate tissue ablation: Sonablate 450 (2015), Ablatherm (2015) and Focal One (2018) [8].
Focal laser ablation (FLA) uses a thin laser fiber placed into the prostate to heat a specific tumor. Like TULSA-PRO, it can be performed under MRI guidance. The energy source is light rather than sound, and it is generally used for a small, well-defined area.
Single-center series: 120 men with low- to intermediate-risk disease, one-year follow-up [9]
Sexual function (SHIM) and urinary symptom (IPSS) scores did not change significantly.
Cryoablation uses thin probes that deliver extremely cold gas to freeze and destroy tissue. It works by cold rather than heat, and it can be used for a focal area or the whole gland.
UK registry: 122 men with focal cryotherapy (71% intermediate-risk, 29% NCCN high-risk), median follow-up 27.8 months [10]
Both functional figures come from the men who returned questionnaires, which is a smaller group than the full registry.
IRE delivers short, high-voltage electrical pulses between electrodes placed around a tumor. The pulses damage cell membranes and cause cell death. IRE is non-thermal, so its effect on tissue near neighboring structures works differently from heat- or cold-based methods.
PRESERVE trial: 121 men with intermediate-risk cancer treated at 17 U.S. centers [11]
The FDA cleared the NanoKnife System in December 2024 based on those findings [12]. Clinical experience with IRE in the prostate is more recent than with HIFU or cryoablation.
The five therapies differ most in energy source and route. Specific devices and techniques vary by provider.
| Therapy | Energy | Typical route | Tissue effect | Guidance |
|---|---|---|---|---|
| TULSA-PRO | Directional ultrasound | Through the urethra | Heat | Real-time MRI temperature monitoring |
| HIFU | Focused ultrasound | Through the rectum | Heat | Ultrasound, commonly with MRI-based planning |
| Focal laser ablation | Laser light | Fiber through the perineum* | Heat | Often MRI |
| Cryoablation | Extreme cold | Probes through the perineum* | Freezing | Typically ultrasound |
| IRE | Electrical pulses | Electrodes through the perineum* | Non-thermal | Typically ultrasound |
*The perineum is the skin between the scrotum and the rectum.
The energy source matters less than whether the treatment fits your specific cancer. These are the questions your care team should be able to answer:
Before you compare the numbers
None of the studies above compares one ablation therapy head to head with another. Each measured a different outcome, in a different group of men, over a different length of time. That is why the numbers cannot be lined up like a scoreboard.
| Therapy | Study | What it measured | Follow-up |
|---|---|---|---|
| TULSA-PRO | TACT [1][5] | PSA reduction, biopsy result, biochemical recurrence-free survival | 12 months and 5 years |
| HIFU | UK multicentre study [6] | Failure-free survival: no radical or systemic therapy, metastases or cancer death | Median 56 months |
| HIFU | HIFI [7] | Salvage-treatment-free survival, compared with prostatectomy | 30 months |
| Focal laser | Single-center series [9] | Freedom from retreatment | 1 year |
| Cryoablation | UK registry [10] | Failure-free survival | Median 27.8 months |
| IRE | PRESERVE [11] | Negative biopsy in the treated area | 12 months |
Every ablation therapy carries risks. Some men have temporary urinary symptoms, and some have changes in erectile function or continence. In some men the cancer remains or returns and needs further treatment. About 22% of TACT participants had received salvage treatment by five years [5]. Ask each provider what follow-up looks like and what the next step would be if cancer is found again.
Ablation data are also shorter-term than the decades of data behind surgery and radiation. A randomized trial comparing TULSA with radical prostatectomy, called CAPTAIN, is underway [13]. Until results like that are available, ask any provider for the published data on the specific device they use and the type of patient studied.
What you may have read
Focal therapy only stuns the cancer, so it is likely to come back.
What the evidence shows
No. Ablation is designed to kill tissue, not to pause it.
Heat-based methods cause coagulative necrosis, cold destroys cells by freezing, and IRE breaks down cell membranes. When men have had the prostate removed after ablation, pathologists have examined the treated zone directly:
Two real findings help explain where the "stun" idea can come from. The first is thermofixation. When tissue heats very fast and very high, cells can keep their shape and look alive under a standard stain even though they are not. In a six-man TULSA treat-and-resect study, one man had a region inside the ablation zone that looked viable on standard staining. Special staining showed changes consistent with thermofixation instead, and the authors noted that this can cause treatment failure to be misinterpreted [16]. The second is the edge of the treated zone. In an early study of 14 men treated with HIFU before surgery, complete necrosis was seen in the treated region in every case. Along the back border, however, destruction was incomplete, and four men had a small viable tumor focus there [19]. That is a targeting and margin problem at the edge, not cells being stunned in the middle.
Recurrence after focal therapy is real, and it comes in two forms:
One review reports in-field recurrence in roughly 8.5% to 17% of men and out-of-field recurrence in roughly 8.0% to 12.3% [20]. Those figures vary by technology, tumor and study.
Follow-up is part of the treatment. PSA is less reliable after focal therapy because the untreated part of the gland still makes PSA. An international consensus prefers multiparametric MRI to check treatment response, and multiple guidelines advocate protocol biopsies of the treated zone [21]. If cancer is found, options include retreatment or other therapy. In TACT, about 22% of men had received salvage treatment by five years [5]. Before you begin any focal therapy, ask what the follow-up schedule is and what the next step would be.
Coverage varies by therapy, device, site of service and plan, and it changes over time. Some payer policies still classify focal ablation as investigational, for example the Federal Employee Program's 2025 medical policy [8]. For TULSA, Category I CPT codes took effect on January 1, 2025, and CMS set Medicare payment rates for the procedure [14]. Whether a specific plan covers a specific procedure at a specific facility is a question for your insurer.
Cost at Integrative Urology
At Integrative Urology, the TULSA-PRO procedure is self-pay. Some pre- and post-procedure care may be covered by insurance. The cost varies case-to-case, but cost starts at about $35,000. Our team walks through the full cost before you commit to anything, and your spouse or partner is welcome on that call or in-person consultation.
Dr. Y. Mark Hong, Integrative Urology
Dr. Y. Mark Hong leads Integrative Urology. He reached 200+ independently performed TULSA-PRO procedures in November 2025, a milestone recognized by Profound Medical, the device's manufacturer [15].
He evaluates every candidate personally. The consultation is where fit is decided, including whether TULSA-PRO is appropriate for you at all.
No. Focal therapy treats only the area of cancer. Whole-gland therapy treats the entire prostate. Several ablation technologies can be planned either way, depending on your imaging and biopsy. In the TACT trial, every man received a whole-gland treatment [1][5].
No trial has compared these ablation therapies head to head, so the honest answer is that it depends on the tumor, the technology and the individual. Ask each provider for the published outcomes for their device and for men with a cancer like yours.
No. They are additional options. Surgery and radiation remain appropriate for many men and have long track records. Your specialist can explain where each one fits.
It depends on the therapy used and your situation. In TACT, about 22% of men had received salvage treatment by five years [5]. Ask about retreatment and follow-up options before you begin, whichever treatment you choose.
No. Ablation is designed to destroy tissue, and treat-and-resect studies found no viable cancer inside well-treated zones [17][18]. Cancer that returns after focal therapy is either in-field, meaning the tumor was not fully treated, or out-of-field, meaning cancer was elsewhere in the gland [20]. Follow-up MRI and biopsy exist to catch both [21].
The procedure at Integrative Urology is self-pay. Category I CPT codes for TULSA took effect in January 2025, and coverage varies by plan and facility [14]. Coverage for other ablation therapies also varies, so verify with your plan.
Learning the differences between these options is a reasonable thing to do slowly. When you are ready, bring your MRI, your biopsy report and your questions. Bring your spouse or partner too if you would like. The goal of a first conversation is for you to understand your options, whichever path you choose.
Request a consultationNumbers in this post come from the sources below, checked as of September 21, 2026.