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
2
Q
Manual probe insertion steps
A
- Dialate rectum 2 fingers2. Apply a thin layer of US gel3. Ballon is deflated enough to slide in without resistance
3
Q
What is the purpose of the sliders on the transverse/longitudinal views
A
Used to measure the prostate volume
4
Q
What is the purpose of the US prostate scan
A
Creates 3D representation of the organ in real time
5
Q
Describe the scanning workflow
A
Scans the postate along the long axis between end points
6
Q
Prostate scanning steps
A
- Place the probe above the bladder neck manually2. Use sw arrow buttons to move probe between the apex and 2nd point
7
Q
Describe the ablation process
A
Focused US soundwaves heat tissue, causing cavitation effect
8
Q
Pads/straps are used to support what 3 areas
A
- back2. legs3. feet
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
10
Q
Goals of a resection prior to treatment
A
- decrease a large prostates volume2. Reduce post-procedure urinary retention
11
Q
Why is a colon prep required
A
- Protects the rectum2. allows optimal energy of sound waves3. infection control
12
Q
What are the four most important patient positioning areas
A
- Pelvis2. Angled knees3. Back 20-30 degrees to the bed exis4. upper back proud and not collapsed
13
Q
What patient data must be input to continue the procedure
A
Fields with an *Focal Pak CodeTreatment protocolTreatment Strategy
14
Q
What is not required, but recommended to increase patient comfort and reduce urinary retention post procedure
A
catheter
15
Q
The Focal Pak is a reposible
A
No
16
Q
What are four purposes of the Focal Pakl
A
- ensures propogation2. indicates code3. Cools rectal wall4. Provides latex probe cover
17
Q
What is the most important landmark when defining the ablation area
A
Apex
18
Q
What is the last slice to be ablated on the bladder side
A
The defined upper limit
19
Q
Between what landmarks is the length of the ablation zone measured
A
Distance between A and U
20
Q
Which direction does the firing process follow
A
L to U
21
Q
Benefits of lesion contour step
A
It better defines the ablation zone, more information
22
Q
Landmarks to consider when on the apex side of prostate
A
- Urethra2. sphincter
23
Q
This isnt nessessary when naviating the upper slides from the side of the apex
A
no yellow lines
24
Q
What does A represent
A
Anatomic Apex
25
What does L represent
First slice on the apex side
26
What does U represent
Last slice on bladder neck side
27
2 solid yellow lines creating a wedge, represents
Heat diffusion zone
28
What funcation does dark blue represent
contouring tool
29
Light blue
Focal points auto-placed
30
What are the 5 fusion steps
1. Import T2 MRI/multiparrameter2. Contour prostate on MRI3. Countor target or ROI4. Contour prostate on US 5. Complete elastic fusion
31
What are the 3 steps of fusing a US with BX
1. Load BX data2. Contour US image3. Complete eleastic fusion
32
Min number of times prostate/target is contoured
3
33
On which image will the limits be placed on the prostate
Longitudinal
34
What are the 4 procedure steps without using fusion
1. Image aquisition2. Prostate volume measured3. A, L, U limits placed4. Transverse contour5. lesion firing
35
What barriers to US soundwaves are found during the prostate scan
1. Gas2. Calcifications
36
Final patient positinging 4
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
37
How is the balloon inflated
Un-clamp at the Ablasonic tube
38
5 contra-indications for Focal One HIFU
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
39
When patient is in the final position before the procedure starts, what is the critical thing to check prior to starting
patient is secured to the bed and all potential patient movement is mitigated
40
What anthastisia equipment should not be used during the procedure
No2 gas, it effectives the efficiency and safety
41
Patient preparation step that allows propagation of US energy and protects the rectum
Colo-prep
42
Purpose of the triangle shaped cushioon
Protects the right shoulder during the procedure
43
What 4 things need to be considered when moving the patient into lat d
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
44
How is the left arm positioned
Using and arm support and a cushion
45
what two conditions need to be met before locating the lesion
A, U, L Treatement area defined
46
What letter deffines the anatomic apex
A
47
When defining the leasion, where should L be placed
1. left of apex2. lower limit of target location
48
What is the A to L distance
Part of the prostate not being treated
49
How is the target area defined
It is the distance between lower and upper limit
50
Where is the orange line positioned
Exactly at the interface between the balloon and rectal wall
51
What is the relationship between the balloon and rectum
Must be in direct contact
52
Which button on the mouse is used to define the contours
Left
53
What is the lesion safety distance
3 mm
54
What is the 4 step process to pause and change the contour area
1. pause2. modify3. re-draw4. fire
55
Next step when rectum/transducer are less than 1 mm apart
Fire
56
Distance between the transducer and rectum is 1-4 mm
Retry with auto followCancel shotadjust probe
57
Desired distance beween probe and rectal wall
23 mm
58
Occurs when the probe is not at 23mm from the rectal wall
1. focal one will readjust or trigger a non-dectection fault
59
When is each new area defined
After each scan
60
What are the 5 stages of prostate/ROI contouring
1. open contouring software2. import mri3. define prostate and suspected zone contour4. copy images and 3 contours to usb5. import into focal 1
61
"No volume detected:
US on HIFU screen reverts to last imagefusion can be performedif fusion is done, it can't be transfereed
62
"New volume, do you want it displayed"
1. Yes2. Us will be the last image3. Fusion can be done4. ROI can be transfered to plan lesions
63
"New volume detected".
New US image was created
64
How long does the fusion process take to complete
1-2 minutes
65
ROI and Prostate contour buttons are displayed when 5
1. fusion ends correctly2. MRI/US are correcte3. padlock closed4. "fusion" display selected 5. Fusion not canceled
66
SV on MRI image
L Limit
67
Apex on MRI
R limit
68
Describes every identified region on MRI or BX
region of interest
69
cross section position loaded to correspond to selection displayued on main screen
Synchronized slice position
70
Process if the patient needs to be re-positioned 4
1. "New aqusition"2. Remove prove and purge balloon3. Correct positoin4. Start again
71
Measure prostate volume steps 5
1. Display prostate at widest/longeset2. define length3. define width4. values displayed5. Volume info box checked
72
"U"
Define upper limit after aquisition
73
Lower limit of prostate length when getting volume
"A" position
74
What is required to localize lesion
1. Limits A/L/U 2. Define treatment area
75
Access to hemi-ablation option
Right click on prostate
76
Line at the interface of the Ablasonic liquid and rectum
Organe Line
77
How to "draw" the rectum
Click 3 points on rectum and confirm with right click
78
Max number of lesions in A/P direction
3
79
Change contour process 4
1. click dark blue circle2. Use pad to deleateClick blue contour line and move using mouse
80
Minimum safe distance lesion to rectum
3 mm
81
Occurs when the target areas turn green
Lesions defined
82
What 3 things does the system constantly monitor
1. probe to wall distance2. power level3. temp cooling unit
83
When is the rectal wall location auto detected
Tracking phase
84
If distance between wall and prostate is less than 1
fire away
85
If distance between wall and probe is 1-4 off
Pause, autocatch up and retry
86
2 action to contour prostate after fusion
1. draw 3 contours cross-section2. determine apex/base
87
what are the 5 condidtions for fusion
1. determine target area2. contour prostate 3 times3. Contour ROI4. Import contours and ROI into HIFU SW5. Determine lowest/highest points
88
What are the 3 types of exported contours
1. porstate2. ROI3. BX
89
Provides a visual indictation for planning/firing
Prostate/Contour/ROI are combined and transfered to treatement screen
90
Casues of fusion error 4
1. previous resection2. hormons3. BX before MRI, cause artifacts4. MRI/US have different values
91
Location of apex on screen
Left side
92
location of SV on screen
Right side
93
Allows user to design prostate contour and ROI
HIFUsion Software
94
Rectal axis is what to long axis of bed
Parrellell
95
Where is the rectal wall in comparision to the orange line
THey are at the same level
96
Probe positioning steps 8
1. ensure clear path2. position probe at the widest point3. balloon inflated
97
Probe positioning steps 8
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
Steps to prepare the ballon for procedure 4
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
Why is the ballon 1/4
THe more the balloon is filled, the thinner/horiztonal the wall becomes
100
Steps before inserting probe
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
Gives information on previous exams/procedures
Previous information menu
102
Mandatory information to be entered prior to procedure
1. focal pak code2. treatement protocol
103
How to move between fields in SW
Shift/tab
104
Action if probe position is too low
Delete slice
105
When can the user add a slice if the probe is "too high:"
When loading first slice
106
Resynchronization limits
+/- 10
107
What is the Anterior/Posterior length max
40mm
108
which screen allows visualization of various volume images and perform eleastic fusion
Imaging screen
109
Used to control treatments, plan contours and make adjustments in real time
Treatment Screen
110
High level procedure steps 7
1. Insertion and alignment2. volume aquisition3. measure volume4. MRI fusion5. treatment plan limits6. define lesion7. deliver treatment
111
Volume aquistion steps 4
1. highlight going past upper/limits2. capture sagistal image3. imbed BK ultrasound
112
Deforms prostate to match size/shape of US and ROI is defined on MRI overlay inthe correct position on US
Elastic/non-ridgid fusion
113
Visual guide to define the area to be ablated
eleastic fusion
114
When a slice is contours, user can do 4 things
1. add note2. click and drag nodes3. slide full countor4. remove nodes from slice
115
Setting treatment plan limits 5
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
What are the 4 safety features
1. Continuous monitoring and re-adjustment to the rectal wall2. Monitor temp3. patient movement4. Monitoring of probe acoustics and electric signals
117
What is the max anterior/posterior ranger
40
118
Patient prep steps 5
1. rectal prep at least 2 hours prior2. empty bladder3. rectum cleaning4. verify wall thickness w/ balloon inflated5. Dialate anal sphincter
119
4 HIFI specific anesthesia consideration
1. No movmemenbt2. dont not over-perfuse3. Right lat d4. Sedate to limit movement
120
Post procedure medication protocol
8 weeks anti-biotics
121
How deep is rectal proabe inserted
Until the prostate and SV is visable
122
Why is knee positoning important
If not as directed, casue lateral popliteal nerve paralysis
123
Where is the balloon in relation to the wall
touching
124
Rectal wall thickening can casue
energy delievered in rectum instead of prostate
125
Max distance from balloon to bottom on the contour
10 mm
126
Consideration for bladder catheter
to be removed when firing in the central zone
127
When does "center motors" occure
Before insertion
128
Distance and temp accuracy
.2 mm and .5 celcius
129
How much Ablasonic fluid fills the balloon
150 - 200 ml
130
What type of fluid is used to fill balloon
Ablasonic
131
5 things to look for when inserting the probe
1.Probe is visually inspected2. Probe mounted3. probe cables are attached/organizated4. movmenets are clampoed5. After motoring centering, ensure index pin is vertical
132
Identifing probe is intalled correctly on mount
1. index pin is lowered2. probe doesnt rotate
133
Before insertion, probe must be...
covered in thin layer of US gel
134
Use to visualize prostate and locate target areas
Imaging Transducer
135
Single use disposable
Focal Pak
136
Four ways to tell that the patient is still and the reflector is properly installed
1. Reflection visable2. blue light on3. No error4. Procedure doesn't pause
137
Light visable to the detector base and communicates patient movment
blue
138
Small square plastic w/ adhesives and reflectors, measures patients movmeent
Reflector
139
Placement of movement detector
Left hip
140
Release button to enable movmement when,
Probe is at desired location
141
Axis used during localization and shooting
1. Longitudinal (X)2. Transverse (Y)3. Rotational
142
Axis for vertical movement in the z plane
Electronic moevement
143
When inserting probe, what type of movements are used
manual
144
3 manual probe movements
1. Longitudinal2. Transverse3. Angular
145
Unfolded on treatment transducer and attached to the probe by a ligature
balloon
146
Starting software steps 4
1. Wait 3-4 minutes2. enter code3. austo test sub-componets4. select "start treamtenet"
147
Ballon installation steps 6
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
Balloon filling steps
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
Leg support componets 3
1. triangular piece w/3 screws2. Rectangle piece3 Cushion
150
Leg support installation steps
1. Fix triangle on table2. assemble triangle using 2 hooks3. adjust length4. cover the componets with pad
151
Patient installation steps 4
1. Put gel pads on table2. position patient3. attached bearhugger4. place reflector on left hip
152
Position of patients anus
left/bottom cornoer
153
which isde of the bed is the patient positioned
Right
154
How should the patients back be positioned
perfectly vertical
155
Pateient head positoin
Antimasressor and gel pads
156
Removing Focal Pak steps 5
1. select "end of treatement"2. Lower pouch and empty3. Remove probe from patient4. Disconnect kit and remove balloon
157
Removing Focal Pak steps 5
1. select "end of treatement"2. Lower pouch and empty3. Remove probe from patient4. Disconnect kit and remove balloon5. Lower Focal Pak stand
158
Removing probe steps 3
1. unhook US cables2. place protective covering on probe and transducer3. remove from mount
159
Ablation procedure steps
1. Define High/Low limits
160
Lower limit of elementary lesion must not be less than
3 mm from rectal wall
161
Indicates distal/proximal extension of the global lesion
Yellow dotted line
162
Global Lesion
stacking of elemental HIFU lesions of different focals
163
Tissue depth limits for global lesion
5-40 mm
164
How many elementary lesions in a global lesion
8-Jan
165
Image displayed on treatment screen in real time
Transverse slice
166
How is the high limit found
Begining of positioning, manually position prove at the SV
167
How is the lower limit defined
Move probe under apex
168
Inferior limit at the level of syphintor
Anatomyical Apex
169
"a"
Anatomical Apex
170
Highest point on target area
upper limit
171
Demarcated by upper/lower limits
Area
172
How many slices per bloc
5-Apr
173
space between rectal wall and posterior face of prostate
prostato-rectal space
174
Ablated volume
Volume calculated from the elementary volume of the lesion
175
3 keys to ablation strategy
1. U doesnt exceed SV2. LL at Apex sphintor3 Do not fire on lesions in the rectal wall or by the sphincter
176
Lowerl limit landmark
At or above apex
177
Upper limit landmark
Level of SV
178
Ablation that targets entire lobe from the apex
hemi
179
4 planning principles of focal ablation
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
Fusion can only be achieved when using
MRI
181
What is the minimum nuber of fires for focal therapy
3
182
If fluid filled cavity is obvserved on US image, empty because
1. US propogates without attenuation in liquid2. patient may feel pain and move3. prostate volume changed
183
To perserve nerves on treated side of prostate
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
3 Considerations when targeting the anterior prostate
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
What is the min distance between the balloon and bottom of targeted lesion
10 mm
186
Max limitd of lesion from rectal wall
40
187
To target down to the apex....
1. limits of phincter are visable on us2. Do not exceed 3 firings per trajectory and no more than 5 trajectories per slice
188
Probe placement considerations 5
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
Lesion planning steps 5
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
