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basics of focal therapy slidedeck > Case Coverage Flash Cards > Flashcards

Case Coverage Flash Cards

a high level overview of procedure steps, patient positioning, processes ect

1
Q

What is the probe starting position

A

MIddle of prostate, positioned facing the ablation target zone

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2
Q

Manual probe insertion steps

A
  1. Dialate rectum 2 fingers2. Apply a thin layer of US gel3. Ballon is deflated enough to slide in without resistance
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3
Q

What is the purpose of the sliders on the transverse/longitudinal views

A

Used to measure the prostate volume

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4
Q

What is the purpose of the US prostate scan

A

Creates 3D representation of the organ in real time

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5
Q

Describe the scanning workflow

A

Scans the postate along the long axis between end points

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6
Q

Prostate scanning steps

A
  1. Place the probe above the bladder neck manually2. Use sw arrow buttons to move probe between the apex and 2nd point
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7
Q

Describe the ablation process

A

Focused US soundwaves heat tissue, causing cavitation effect

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8
Q

Pads/straps are used to support what 3 areas

A
  1. back2. legs3. feet
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9
Q

When positioning the patien twhat special considerations are required for the chest/shoulders

A

between 20-30 degree angle to the axis of the bed, chest proud and not collapsing in either direction

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10
Q

Goals of a resection prior to treatment

A
  1. decrease a large prostates volume2. Reduce post-procedure urinary retention
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11
Q

Why is a colon prep required

A
  1. Protects the rectum2. allows optimal energy of sound waves3. infection control
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12
Q

What are the four most important patient positioning areas

A
  1. Pelvis2. Angled knees3. Back 20-30 degrees to the bed exis4. upper back proud and not collapsed
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13
Q

What patient data must be input to continue the procedure

A

Fields with an *Focal Pak CodeTreatment protocolTreatment Strategy

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14
Q

What is not required, but recommended to increase patient comfort and reduce urinary retention post procedure

A

catheter

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15
Q

The Focal Pak is a reposible

A

No

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16
Q

What are four purposes of the Focal Pakl

A
  1. ensures propogation2. indicates code3. Cools rectal wall4. Provides latex probe cover
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17
Q

What is the most important landmark when defining the ablation area

A

Apex

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18
Q

What is the last slice to be ablated on the bladder side

A

The defined upper limit

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19
Q

Between what landmarks is the length of the ablation zone measured

A

Distance between A and U

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20
Q

Which direction does the firing process follow

A

L to U

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21
Q

Benefits of lesion contour step

A

It better defines the ablation zone, more information

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22
Q

Landmarks to consider when on the apex side of prostate

A
  1. Urethra2. sphincter
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23
Q

This isnt nessessary when naviating the upper slides from the side of the apex

A

no yellow lines

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24
Q

What does A represent

A

Anatomic Apex

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25
Q

What does L represent

A

First slice on the apex side

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26
Q

What does U represent

A

Last slice on bladder neck side

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27
Q

2 solid yellow lines creating a wedge, represents

A

Heat diffusion zone

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28
Q

What funcation does dark blue represent

A

contouring tool

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29
Q

Light blue

A

Focal points auto-placed

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30
Q

What are the 5 fusion steps

A
  1. Import T2 MRI/multiparrameter2. Contour prostate on MRI3. Countor target or ROI4. Contour prostate on US 5. Complete elastic fusion
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31
Q

What are the 3 steps of fusing a US with BX

A
  1. Load BX data2. Contour US image3. Complete eleastic fusion
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32
Q

Min number of times prostate/target is contoured

A

3

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33
Q

On which image will the limits be placed on the prostate

A

Longitudinal

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34
Q

What are the 4 procedure steps without using fusion

A
  1. Image aquisition2. Prostate volume measured3. A, L, U limits placed4. Transverse contour5. lesion firing
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35
Q

What barriers to US soundwaves are found during the prostate scan

A
  1. Gas2. Calcifications
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36
Q

Final patient positinging 4

A
  1. Back 20-30 degrees relative to the bed axis2. Pelvis at the right bottom cornor of the bed3. Knees lifted and in line with left lef4. Bony promentories are paded and stapes secure the patient in position
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37
Q

How is the balloon inflated

A

Un-clamp at the Ablasonic tube

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38
Q

5 contra-indications for Focal One HIFU

A
  1. Localized in the anterior apex2. Any rectal abnormalitities like shadow on US3. Prostate calcifications4. Prostorectal space is bigger than 10mm5. Patient has latex allergy
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39
Q

When patient is in the final position before the procedure starts, what is the critical thing to check prior to starting

A

patient is secured to the bed and all potential patient movement is mitigated

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40
Q

What anthastisia equipment should not be used during the procedure

A

No2 gas, it effectives the efficiency and safety

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41
Q

Patient preparation step that allows propagation of US energy and protects the rectum

A

Colo-prep

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42
Q

Purpose of the triangle shaped cushioon

A

Protects the right shoulder during the procedure

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43
Q

What 4 things need to be considered when moving the patient into lat d

A
  1. Pelvis at bottom right cornor2. angled knees3. Back is 20-30 degree angle from the bed axis4. Upper back is neautral, no lean one way or another
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44
Q

How is the left arm positioned

A

Using and arm support and a cushion

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45
Q

what two conditions need to be met before locating the lesion

A

A, U, L Treatement area defined

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46
Q

What letter deffines the anatomic apex

A

A

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47
Q

When defining the leasion, where should L be placed

A
  1. left of apex2. lower limit of target location
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48
Q

What is the A to L distance

A

Part of the prostate not being treated

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49
Q

How is the target area defined

A

It is the distance between lower and upper limit

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50
Q

Where is the orange line positioned

A

Exactly at the interface between the balloon and rectal wall

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51
Q

What is the relationship between the balloon and rectum

A

Must be in direct contact

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52
Q

Which button on the mouse is used to define the contours

A

Left

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53
Q

What is the lesion safety distance

A

3 mm

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54
Q

What is the 4 step process to pause and change the contour area

A
  1. pause2. modify3. re-draw4. fire
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55
Q

Next step when rectum/transducer are less than 1 mm apart

A

Fire

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56
Q

Distance between the transducer and rectum is 1-4 mm

A

Retry with auto followCancel shotadjust probe

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57
Q

Desired distance beween probe and rectal wall

A

23 mm

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58
Q

Occurs when the probe is not at 23mm from the rectal wall

A
  1. focal one will readjust or trigger a non-dectection fault
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59
Q

When is each new area defined

A

After each scan

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60
Q

What are the 5 stages of prostate/ROI contouring

A
  1. open contouring software2. import mri3. define prostate and suspected zone contour4. copy images and 3 contours to usb5. import into focal 1
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61
Q

“No volume detected:

A

US on HIFU screen reverts to last imagefusion can be performedif fusion is done, it can’t be transfereed

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62
Q

“New volume, do you want it displayed”

A
  1. Yes2. Us will be the last image3. Fusion can be done4. ROI can be transfered to plan lesions
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63
Q

“New volume detected”.

A

New US image was created

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64
Q

How long does the fusion process take to complete

A

1-2 minutes

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65
Q

ROI and Prostate contour buttons are displayed when 5

A
  1. fusion ends correctly2. MRI/US are correcte3. padlock closed4. “fusion” display selected 5. Fusion not canceled
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66
Q

SV on MRI image

A

L Limit

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67
Q

Apex on MRI

A

R limit

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68
Q

Describes every identified region on MRI or BX

A

region of interest

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69
Q

cross section position loaded to correspond to selection displayued on main screen

A

Synchronized slice position

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70
Q

Process if the patient needs to be re-positioned 4

A
  1. “New aqusition”2. Remove prove and purge balloon3. Correct positoin4. Start again
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71
Q

Measure prostate volume steps 5

A
  1. Display prostate at widest/longeset2. define length3. define width4. values displayed5. Volume info box checked
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72
Q

“U”

A

Define upper limit after aquisition

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73
Q

Lower limit of prostate length when getting volume

A

“A” position

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74
Q

What is required to localize lesion

A
  1. Limits A/L/U 2. Define treatment area
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75
Q

Access to hemi-ablation option

A

Right click on prostate

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76
Q

Line at the interface of the Ablasonic liquid and rectum

A

Organe Line

77
Q

How to “draw” the rectum

A

Click 3 points on rectum and confirm with right click

78
Q

Max number of lesions in A/P direction

A

3

79
Q

Change contour process 4

A
  1. click dark blue circle2. Use pad to deleateClick blue contour line and move using mouse
80
Q

Minimum safe distance lesion to rectum

A

3 mm

81
Q

Occurs when the target areas turn green

A

Lesions defined

82
Q

What 3 things does the system constantly monitor

A
  1. probe to wall distance2. power level3. temp cooling unit
83
Q

When is the rectal wall location auto detected

A

Tracking phase

84
Q

If distance between wall and prostate is less than 1

A

fire away

85
Q

If distance between wall and probe is 1-4 off

A

Pause, autocatch up and retry

86
Q

2 action to contour prostate after fusion

A
  1. draw 3 contours cross-section2. determine apex/base
87
Q

what are the 5 condidtions for fusion

A
  1. determine target area2. contour prostate 3 times3. Contour ROI4. Import contours and ROI into HIFU SW5. Determine lowest/highest points
88
Q

What are the 3 types of exported contours

A
  1. porstate2. ROI3. BX
89
Q

Provides a visual indictation for planning/firing

A

Prostate/Contour/ROI are combined and transfered to treatement screen

90
Q

Casues of fusion error 4

A
  1. previous resection2. hormons3. BX before MRI, cause artifacts4. MRI/US have different values
91
Q

Location of apex on screen

A

Left side

92
Q

location of SV on screen

A

Right side

93
Q

Allows user to design prostate contour and ROI

A

HIFUsion Software

94
Q

Rectal axis is what to long axis of bed

A

Parrellell

95
Q

Where is the rectal wall in comparision to the orange line

A

THey are at the same level

96
Q

Probe positioning steps 8

A
  1. ensure clear path2. position probe at the widest point3. balloon inflated
97
Q

Probe positioning steps 8

A
  1. ensure clear path2. position probe at the widest point3. balloon inflatedrectal4. rectal wall same level as orange line5. retum is flat circle6. probe 23 mm from wall7. move probe from apex to neck8. Ensure orange line is still visable and sligned with rectal wall
98
Q

Steps to prepare the ballon for procedure 4

A
  1. fill balloon2. close clamp with 3/4 empty3. Fill half a syringe with fluid and conntect to bubble trap4. Ensure balloon is still in patient
99
Q

Why is the ballon 1/4

A

THe more the balloon is filled, the thinner/horiztonal the wall becomes

100
Q

Steps before inserting probe

A
  1. Drain balloon2. Cover balloon in thin layer of US gel3. digitial dilation4. table height it correct5. Move machine6. insert probe using key pad
101
Q

Gives information on previous exams/procedures

A

Previous information menu

102
Q

Mandatory information to be entered prior to procedure

A
  1. focal pak code2. treatement protocol
103
Q

How to move between fields in SW

A

Shift/tab

104
Q

Action if probe position is too low

A

Delete slice

105
Q

When can the user add a slice if the probe is “too high:”

A

When loading first slice

106
Q

Resynchronization limits

A

+/- 10

107
Q

What is the Anterior/Posterior length max

A

40mm

108
Q

which screen allows visualization of various volume images and perform eleastic fusion

A

Imaging screen

109
Q

Used to control treatments, plan contours and make adjustments in real time

A

Treatment Screen

110
Q

High level procedure steps 7

A
  1. Insertion and alignment2. volume aquisition3. measure volume4. MRI fusion5. treatment plan limits6. define lesion7. deliver treatment
111
Q

Volume aquistion steps 4

A
  1. highlight going past upper/limits2. capture sagistal image3. imbed BK ultrasound
112
Q

Deforms prostate to match size/shape of US and ROI is defined on MRI overlay inthe correct position on US

A

Elastic/non-ridgid fusion

113
Q

Visual guide to define the area to be ablated

A

eleastic fusion

114
Q

When a slice is contours, user can do 4 things

A
  1. add note2. click and drag nodes3. slide full countor4. remove nodes from slice
115
Q

Setting treatment plan limits 5

A
  1. move yellow line to show current volume2. point yellow ling ROI3. place apex marker with yellow line4. place transverse/sagital yellow live at center of lesions5. place U/L markers close to ROI
116
Q

What are the 4 safety features

A
  1. Continuous monitoring and re-adjustment to the rectal wall2. Monitor temp3. patient movement4. Monitoring of probe acoustics and electric signals
117
Q

What is the max anterior/posterior ranger

A

40

118
Q

Patient prep steps 5

A
  1. rectal prep at least 2 hours prior2. empty bladder3. rectum cleaning4. verify wall thickness w/ balloon inflated5. Dialate anal sphincter
119
Q

4 HIFI specific anesthesia consideration

A
  1. No movmemenbt2. dont not over-perfuse3. Right lat d4. Sedate to limit movement
120
Q

Post procedure medication protocol

A

8 weeks anti-biotics

121
Q

How deep is rectal proabe inserted

A

Until the prostate and SV is visable

122
Q

Why is knee positoning important

A

If not as directed, casue lateral popliteal nerve paralysis

123
Q

Where is the balloon in relation to the wall

A

touching

124
Q

Rectal wall thickening can casue

A

energy delievered in rectum instead of prostate

125
Q

Max distance from balloon to bottom on the contour

A

10 mm

126
Q

Consideration for bladder catheter

A

to be removed when firing in the central zone

127
Q

When does “center motors” occure

A

Before insertion

128
Q

Distance and temp accuracy

A

.2 mm and .5 celcius

129
Q

How much Ablasonic fluid fills the balloon

A

150 - 200 ml

130
Q

What type of fluid is used to fill balloon

A

Ablasonic

131
Q

5 things to look for when inserting the probe

A

1.Probe is visually inspected2. Probe mounted3. probe cables are attached/organizated4. movmenets are clampoed5. After motoring centering, ensure index pin is vertical

132
Q

Identifing probe is intalled correctly on mount

A
  1. index pin is lowered2. probe doesnt rotate
133
Q

Before insertion, probe must be…

A

covered in thin layer of US gel

134
Q

Use to visualize prostate and locate target areas

A

Imaging Transducer

135
Q

Single use disposable

A

Focal Pak

136
Q

Four ways to tell that the patient is still and the reflector is properly installed

A
  1. Reflection visable2. blue light on3. No error4. Procedure doesn’t pause
137
Q

Light visable to the detector base and communicates patient movment

A

blue

138
Q

Small square plastic w/ adhesives and reflectors, measures patients movmeent

A

Reflector

139
Q

Placement of movement detector

A

Left hip

140
Q

Release button to enable movmement when,

A

Probe is at desired location

141
Q

Axis used during localization and shooting

A
  1. Longitudinal (X)2. Transverse (Y)3. Rotational
142
Q

Axis for vertical movement in the z plane

A

Electronic moevement

143
Q

When inserting probe, what type of movements are used

A

manual

144
Q

3 manual probe movements

A
  1. Longitudinal2. Transverse3. Angular
145
Q

Unfolded on treatment transducer and attached to the probe by a ligature

A

balloon

146
Q

Starting software steps 4

A
  1. Wait 3-4 minutes2. enter code3. austo test sub-componets4. select “start treamtenet”
147
Q

Ballon installation steps 6

A

1,. remove and unroll balloon on probe2. remove 3-4 cm of ligature and stretch balloon with right hands3. Attach ligature4. Stretch ligature around probe without covering black transducer5. Move ligature towards the body of the probe6. leave a tab for removal

148
Q

Balloon filling steps

A
  1. Mount Ablasonic pouch on stand2. connect tube and open clamp3. Run pump4. Manually remove bubbles5. run pump as long as there are buddles or 10 minutes6. Unhook pouch7. unclamp and fill 30 cc
149
Q

Leg support componets 3

A
  1. triangular piece w/3 screws2. Rectangle piece3 Cushion
150
Q

Leg support installation steps

A
  1. Fix triangle on table2. assemble triangle using 2 hooks3. adjust length4. cover the componets with pad
151
Q

Patient installation steps 4

A
  1. Put gel pads on table2. position patient3. attached bearhugger4. place reflector on left hip
152
Q

Position of patients anus

A

left/bottom cornoer

153
Q

which isde of the bed is the patient positioned

A

Right

154
Q

How should the patients back be positioned

A

perfectly vertical

155
Q

Pateient head positoin

A

Antimasressor and gel pads

156
Q

Removing Focal Pak steps 5

A
  1. select “end of treatement”2. Lower pouch and empty3. Remove probe from patient4. Disconnect kit and remove balloon
157
Q

Removing Focal Pak steps 5

A
  1. select “end of treatement”2. Lower pouch and empty3. Remove probe from patient4. Disconnect kit and remove balloon5. Lower Focal Pak stand
158
Q

Removing probe steps 3

A
  1. unhook US cables2. place protective covering on probe and transducer3. remove from mount
159
Q

Ablation procedure steps

A
  1. Define High/Low limits
160
Q

Lower limit of elementary lesion must not be less than

A

3 mm from rectal wall

161
Q

Indicates distal/proximal extension of the global lesion

A

Yellow dotted line

162
Q

Global Lesion

A

stacking of elemental HIFU lesions of different focals

163
Q

Tissue depth limits for global lesion

A

5-40 mm

164
Q

How many elementary lesions in a global lesion

A

8-Jan

165
Q

Image displayed on treatment screen in real time

A

Transverse slice

166
Q

How is the high limit found

A

Begining of positioning, manually position prove at the SV

167
Q

How is the lower limit defined

A

Move probe under apex

168
Q

Inferior limit at the level of syphintor

A

Anatomyical Apex

169
Q

“a”

A

Anatomical Apex

170
Q

Highest point on target area

A

upper limit

171
Q

Demarcated by upper/lower limits

A

Area

172
Q

How many slices per bloc

A

5-Apr

173
Q

space between rectal wall and posterior face of prostate

A

prostato-rectal space

174
Q

Ablated volume

A

Volume calculated from the elementary volume of the lesion

175
Q

3 keys to ablation strategy

A
  1. U doesnt exceed SV2. LL at Apex sphintor3 Do not fire on lesions in the rectal wall or by the sphincter
176
Q

Lowerl limit landmark

A

At or above apex

177
Q

Upper limit landmark

A

Level of SV

178
Q

Ablation that targets entire lobe from the apex

A

hemi

179
Q

4 planning principles of focal ablation

A
  1. postion probe opposite area targeted2. L is at lowerl target limits3. Fusion before position targets4. Plane at least 3 trajectories in increase efficacy
180
Q

Fusion can only be achieved when using

A

MRI

181
Q

What is the minimum nuber of fires for focal therapy

A

3

182
Q

If fluid filled cavity is obvserved on US image, empty because

A
  1. US propogates without attenuation in liquid2. patient may feel pain and move3. prostate volume changed
183
Q

To perserve nerves on treated side of prostate

A
  1. don’t include area in contour2. minimize number of leasions near nerves, define globla region with 1 or 2 elementary lesions in the area
184
Q

3 Considerations when targeting the anterior prostate

A
  1. No foley2. If target area is greater than 40mm from wall, can’t be reached3. Do not generate lesions if the distiance between the balloon and bottom of the contour exeeds mm
185
Q

What is the min distance between the balloon and bottom of targeted lesion

A

10 mm

186
Q

Max limitd of lesion from rectal wall

A

40

187
Q

To target down to the apex….

A
  1. limits of phincter are visable on us2. Do not exceed 3 firings per trajectory and no more than 5 trajectories per slice
188
Q

Probe placement considerations 5

A
  1. move longitudinally to widest part2. Organe dotted line at rectal wall3. rectum is flat4. probe centered in rectum5. set upper and lower limits
189
Q

Lesion planning steps 5

A
  1. confirm slice2. define no lesions in P/R space, in the sphincter or in catheter3. after all lesions are defined, fire4. Do not plan shots for lesions in rectum or catheter

basics of focal therapy slidedeck (12 decks)

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