Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation for Localized Prostate Cancer: A GRADE-Assessed Systematic Review and Meta-Analysis.

PURPOSE: To evaluate technical, oncologic, safety, and functional outcomes following magnetic resonance imaging-guided transurethral ultrasound ablation (TULSA) for localized prostate cancer (PCa). MATERIALS AND METHODS: A systematic search across PubMed, Embase, Scopus, Cochrane (CENTRAL), and ClinicalTrials.gov through February 2026 identified studies reporting TULSA outcomes for localized PCa in treatment-naive or salvage settings. Random-effects meta-analysis was performed. Subgroup analyses stratified outcomes by treatment intent and sensitivity analyses excluded the largest retrospective study. Heterogeneity (I2 and τ2) and evidence certainty (GRADE) were assessed. RESULTS: Thirteen studies comprising 650 patients were included. TULSA demonstrated universal technical success (100%, I2 = 0%). Major complications (grade ≥ 3) occurred in 2% (95% CI: 0-5%, I2 = 24.9%). Continence was preserved in 97% of treatment-naive patients (95% CI: 91-100%, I2 = 52.6%) versus 47% in the salvage setting (95% CI: 26-68%) (p < 0.0001). PSA decreased by a mean of 5.02 ng/mL (95% CI: - 5.76 to - 4.27, p < 0.0001, I2 = 60.4%), representing an 85% reduction from baseline. Biochemical recurrence occurred in 13% (95% CI: 4-35%, I2 = 87.4%), clinically significant cancer on biopsy in 22% (95% CI: 11-38%, I2 = 86.0%), and salvage treatment progression in 14% (95% CI: 6-28%, I2 = 84.4%). IPSS change (- 1.64, p = 0.25) and erectile function (SMD: - 0.23, p = 0.09) were non-significant and below minimum clinically important differences. CONCLUSION: TULSA demonstrated excellent technical feasibility and minimal major morbidity (moderate certainty). Continence preservation was substantially better in treatment-naive than salvage patients. Oncologic and erectile function outcomes remain very low certainty due to high heterogeneity and 36-month maximum follow-up. Current evidence supports TULSA for carefully selected treatment-naive patients, pending long-term comparative data. LEVEL OF EVIDENCE: Level 2a, Systematic Review and Meta-Analysis including Observational Studies.