Automated image-guided tissue ablation and treatment

Abstract

To provide an improved method and apparatus for performing tissue resection, such as prostate tissue resection.SOLUTION: A system for treating a patient includes a user interface that allows a physician to view an image of tissue to be treated in order to develop a treatment plan for resecting the tissue with a predetermined removal profile. The image may include a plurality of images and the planned treatment is indicated on the image. The treatment probe may comprise an anchor, and the image shown on the screen may have a reference image marker shown on the screen corresponding to the anchor. The planned tissue removal profile may be displayed and can be scaled to an image of the target tissue of the organ, such as the prostate, and the physician can adjust the treatment profile based on the scaled image to provide the treatment profile in three dimensions. The image shown on the display may comprise a segmented image of the patient with the treatment plan overlaid on the image.SELECTED DRAWING: None

Description

[Technical Field]

[0001] CROSS-REFERENCE This PCT application claims priority to U.S. Provisional Patent Application No. 61 / 604,932, entitled "AUTOMATED IMAGE-GUIDED INTRA-ORGAN RESECTION AND TREATMENT," filed February 29, 2012 [Attorney Docket No. 41502-705.101], the entire disclosure of which is incorporated herein by reference.

[0002] The subject matter of this PCT application is related to the following commonly owned U.S. patents and pending applications, the entire disclosures of which are incorporated by reference: U.S. Patent Application Serial No. 12 / 399,585, filed March 6, 2009, entitled "TISSUE ABLATION AND CAUTERY WITH OPTICAL ENERGY CARRIED IN FLUID STREAM," published as U.S. Patent Application Publication No. 20090227998 [Attorney Docket No. 41502-704.201]; U.S. Patent Application Serial No. 12 / 700,568, filed February 4, 2010, entitled "MULTI FLUID TISSUE RESECTION METHODS AND DEVICES," published as U.S. Patent Application Publication No. 20110184391 [Attorney Docket No. 41502-703.501]; and U.S. Patent Application Serial No. 12 / 700,568, filed February 8, 2011, entitled "MINIMALLY INVASIVE TISSUE RESECTION METHODS AND DEVICES," published as U.S. Patent Application Publication No. 20110184391 [Attorney Docket No. 41502-703.501]. U.S. Patent No. 7,882,841 [Attorney Docket No. 41502-703.201] entitled "METHODS AND DEVICES FOR THE TREATMENT OF PROSTATE DISEASES."

[0003] The subject matter of this application is also related to PCT application PCT / US2011 / 023781, entitled "MULTI FLUID TISSUE RESECTION METHODS AND DEVICES," filed April 8, 2007, and published November 8, 2011 as WO2011097505, the entire disclosure of which is incorporated herein by reference. [Background technology]

[0004] The field of the invention relates to the treatment of tissue with energy, and more particularly to the treatment of organs such as the prostate with fluid flow energy.

[0005] Prior art methods and devices for treating subjects, such as patients, may, at least in some cases, result in less-than-ideal removal. For example, prior art methods of prostate surgery may, at least in some cases, result in longer healing times than would be ideal and less-than-desirable outcomes.

[0006] Prior art methods and devices for imaging tissue may be less than ideal for imaging treated tissue. For example, prior art ultrasound methods and devices may not be suitable for viewing the treatment field during treatment, and alignment of diagnostic images with treatment images may be less than ideal. Additionally, at least some of the prior art therapeutic methods and devices for treating tissue may not be suitable for use in combination with prior art imaging systems. At least in some cases, it would be useful to provide improved imaging of tissue during surgery, such as providing real-time imaging of tissue, which would allow a user to adjust treatment based on real-time images of the tissue. At least some of the prior art methods and devices for imaging tissue during surgery may be somewhat cumbersome to use and may result in delays in patient treatment.

[0007] Prior art methods and devices for treating organs such as the prostate may provide user interfaces that are somewhat cumbersome for the user and may provide less-than-ideal planning of the procedure. Also, at least some of the prior art methods and devices for treating tissue such as prostate tissue may be somewhat less accurate than would be ideal. At least in some cases, prior art methods and devices may provide a less-than-ideal user experience. Also, at least some of the prior art interfaces may provide less-than-ideal coupling of the treatment device with the tissue structure.

[0008] Improved methods for tissue ablation are described in U.S. Patent No. 7,882,841 and pending U.S. patent applications Ser. Nos. 12 / 700,568 and 12 / 399,585. The methods and systems described in this patent and these applications rely on the positioning of a probe, such as a urethral probe, to direct a fluid flow radially outward for controlled ablation of tissue, such as prostate and luminal tissue. Optionally, the fluid flow may be used to deliver light, electricity, heat, or other energy sources to aid in the ablation and / or to cauterize the treated tissue.

[0009] While these methods are highly effective and represent a significant advance over prior art luminal tissue treatment protocols, it would be desirable to provide improvements to support more precise tissue removal in both fully automatic and physician-assisted modes of operation. At least some of these objectives will be met by the inventions described herein. [Prior art documents] [Patent documents]

[0010] [Patent Document 1] U.S. Patent No. 7,882,841 Summary of the Invention [Means for solving the problem]

[0011] Embodiments of the present invention provide improved methods and devices for performing tissue ablation, such as prostate tissue ablation, by positioning an energy source within the urethra. Energy is directed radially outward from the energy source toward tissue within the prostate, which may include the wall of the urethra. The energy source is moved to remove a predetermined volume of tissue surrounding the lumen, and the movement of the energy source is controlled at least in part by an automatic controller.

[0012] In many embodiments, a user interface is demonstrated that allows a physician to view an image of the tissue to be treated, such as prostate tissue. The image may comprise multiple images, and a planned treatment is shown to the physician on a display. The treatment probe may comprise anchors, and the image shown on the screen may have reference image markers shown on the screen corresponding to the anchors. The planned tissue removal profile can be displayed and scaled to the image of the target tissue in an organ, such as the prostate, and the physician can adjust the treatment profile based on the scaled image. The treatment profile can be simultaneously overlaid on multiple images of the tissue to be treated. In many embodiments, sagittal and axial views of the tissue are displayed, and a treatment profile of a predetermined volume is shown sagittal and axially at a scale substantially similar to the image so that the treatment can be planned.

[0013] In many embodiments, the treatment probe includes a linkage coupled to the anchor to precisely direct energy to the target tissue location. In many embodiments, the linkage is secured to the anchor using a spine extending between the anchor and the linkage to precisely direct energy to the target tissue when the anchor is positioned inside the patient. The treatment probe may include an elongated structure having a working channel, which may include an elongated element such as a shaft. The elongated structure may include a spine to add stiffness and rigidity, and the anchor may be provided on a distal end of the elongated structure. A carrier, such as a carrier tube, moves within the working channel under the control of a linkage coupled to a controller. The linkage includes a first fixed portion that provides a frame of reference for directing energy to the target tissue when the anchor is secured to the linkage, and a second moving portion that drives the carrier in rotation and translation to direct energy to the target tissue.

[0014] In many embodiments, the treatment probe's coordinate reference system is shown on the display, and images shown on the display are mapped to the treatment probe's coordinate reference system, making it easier for the user to plan the treatment and ensuring that the treatment is properly aligned with the tissue. The treatment probe may have a longitudinal axis, and images of tissue and tissue structures shown on the display can be referenced by the user with respect to the longitudinal axis treatment coordinate reference system. The radially extending ablation distance of the profile may be shown on the display with reference to a radius extending from the longitudinal axis, and the radius can vary with angle around the axis to provide a predetermined volume with a three-dimensional ablation profile.

[0015] In many embodiments, energy flow markers are shown on the image shown on the display, and the energy flow markers can be moved across the screen during treatment. Energy flow location can be shown on sagittal and axial views. The energy flow location can be rotationally changed along the axial view to correspond to the sweeping motion of the energy flow around the longitudinal axis of the probe, and the longitudinal position of the energy flow can be moved along the sagittal view of the tissue and treatment profile to indicate the location of the energy flow along the longitudinal axis of the treatment. The image of the moving energy flow shown on the display can be shown in real time to give the user an indication of the progress and completeness of the treatment.

[0016] The image of the tissue shown on the display may comprise a user-identifiable tissue structure or may comprise tissue of an organ having an identifiable tissue structure of the organ, such as the prostate. The image of the target tissue shown on the display may comprise one or more of an anatomical representation of the tissue to be treated, an image of the patient to be treated, a pre-operative image of the tissue to be treated, or a real-time image of the patient's tissue as the patient is being treated. The image of the target tissue shown on the display may include the structure of the target tissue and may comprise an image of the organ containing the target tissue.

[0017] In many embodiments, three-dimensional data of a patient's target tissue may be obtained and displayed to a user as a three-dimensional representation. The three-dimensional data may be shown in sagittal and axial cross-sectional views, and the cross-sectional views may include segmentation of the target tissue. The three-dimensional data may be obtained in one or more of many ways and may comprise ultrasound data, magnetic resonance imaging data, positron emission tomography data, or computed tomography data. In many embodiments, three-dimensional data of the prostate is obtained and segmented images along sagittal and transverse planes are displayed to a user.

[0018] An image of the patient shown on the display can be mapped and aligned to the treatment coordinate reference system, and the mapped treatment profile is shown on the patient image. The image of the patient can include one or more structures of a probe inserted into the patient, and the structures of the probe in the image can be identified to align the image with markers of the treatment plan shown on the display. The identified structures of the patient image can include an anchored balloon in an expanded configuration, and the balloon can be aligned with the anchor reference markers of the treatment plan.

[0019] Additional reference markers may be provided on the image to enable treatment planning, and in many embodiments, these reference markers can be verified prior to treatment. Additional structures on the patient image can be identified and aligned with additional reference markers on the treatment plan to align the patient image with the treatment plan. The patient image can be mapped to the treatment probe coordinate reference system. Alternatively, or in combination, the treatment plan, including the treatment profile and predetermined treatment volume, can be mapped from the treatment probe coordinate reference system to the patient image coordinate reference system provided by the imaging probe.

[0020] In many embodiments, the treatment probe and the imaging probe are coupled to provide precise alignment of the treatment probe and the imaging probe. The treatment probe and the imaging probe can be coupled in many ways. In many embodiments, the treatment probe and the imaging probe are coupled to a common base. Alternatively, or in combination, a magnet can be provided to couple the imaging probe to the treatment probe. A first arm can extend from the base to the elongated treatment probe, and a second arm can extend from the base to the elongated imaging probe. The first arm and the second arm can each include a first movable configuration that allows the arm to be moved to insert the probe into the patient and a second locking configuration that prevents movement of the arm. The second arm can include an actuator to enable fine movement and positioning of the imaging probe to align it with the treatment probe and the target tissue.

[0021] In many embodiments, angle sensors are provided to determine the angular orientation of one or more of the imaging probe or therapy probe. Each angle sensor can be connected to, e.g., fixed to, the probe such that the angle sensor can be used to determine the orientation of the elongate axis of the probe and the rotation of the probe about the elongate axis. Each angle sensor can include one or more of a goniometer or an accelerometer, and can include a three-dimensional angle sensor such as a three-dimensional accelerometer.

[0022] The treatment probe and imaging probe can be inserted into the patient in one or more of many ways. In many embodiments, the imaging probe is inserted into a first side of the patient and the treatment probe is inserted into a second side of the patient. The imaging probe may comprise a transrectal ultrasound probe inserted into the patient's posterior side, and the treatment probe is inserted into the patient's urethra from the patient's anterior side.

[0023] In many embodiments, the treatment probe is configured to image the target tissue. The treatment probe includes an elongated structure having a working channel sized to receive an endoscope and a carrier tube carrier configured to direct and scan a light beam over the treatment area to determine a profile of the tissue to be removed. The carrier can be configured to emit a fluid stream containing a waveguide and scan the light pattern of the fluid stream containing the waveguide. The profile of the removed tissue can be determined based on the location of the light beam from the endoscopic image. Alternatively, or in combination, the carrier can include at least one acoustic transducer to measure the location of the remaining tissue and provide a tissue ablation profile. The longitudinal location of the carrier and the angular orientation of the carrier can be determined based on controller commands to a linkage used to position the carrier relative to the anchor.

[0024] In many embodiments, the manifold is connected to the proximal end of the elongate structure, and a coupling joint is provided between the linkage and the manifold to allow the linkage to be decoupled from the patient while the elongate structure and anchor remain positioned within the patient. The manifold includes multiple ports and multiple channels coupled to the treatment site for one or more of irrigation, insufflation, or inflation of the anchoring balloon. A manifold that remains connected to the elongate structure having a working channel when the linkage is not connected has many advantages. The elongate structure can be configured in many ways, and may comprise an elongate tubular shaft structure defining a working channel, multiple channels, and a sheath. The working channel, multiple channels, and sheath of the elongate structure may extend from the manifold to the work site. In many embodiments, the elongate structure includes a rigid element that adds rigidity and stiffness, such as a spine extending from the manifold to the anchor, and the spine may comprise a rigid or rigid tubular member. The manifold enables fluid delivery to the treatment site using an elongate structure with one or more fluid delivery channels and a sheath extending around the spine. The surgical site can be accessed with surgical tools and an imaging device, such as an endoscope, when the anchor includes an expanded configuration. The elongate structure can be advanced to the treatment site, and the anchor can be expanded prior to coupling the link to the elongate structure.

[0025] In a first aspect, embodiments provide a method for tissue ablation, the method including positioning an energy source within tissue, directing energy radially outward from the energy source toward the tissue, and moving the energy source to remove a predetermined volume of tissue, the movement of the energy source being controlled at least in part by an automated controller.

[0026] In another aspect, embodiments provide a method for tissue ablation of an organ such as the prostate. An energy source is positioned within a urethra having a lumen. Energy is directed radially outward from the energy source toward a wall of the urethra within the prostate. The energy source is moved to remove a predetermined volume of tissue surrounding the lumen, the movement of the energy source being controlled at least in part by an automated controller.

[0027] In many embodiments, an automatic controller controls the movement of the energy source based on a pre-defined plan.

[0028] In many embodiments, an automatic controller controls the movement of the energy source based on a pre-defined plan.

[0029] In many embodiments, the default plan is input by the user based on pre-operative images of the prostate.

[0030] In many embodiments, the automatic controller controls the movement of the energy source based on real-time assessment of the prostate gland.

[0031] In many embodiments, the real-time assessment includes interstitial laser-guided imaging.

[0032] In many embodiments, the real-time assessment includes acoustic distance measurements.

[0033] In many embodiments, the real-time assessment involves sound-guided differentiation in tissue.

[0034] In many embodiments, the automatic control further includes pulse width modulation.

[0035] In many embodiments, the user overrides the automatic control.

[0036] In many embodiments, an image of the prostate gland is provided on a display coupled to the processor, the display being viewable by a user. A plurality of input parameters corresponding to an axial length and a radial distance of a predetermined volume of tissue are received. A predetermined tissue removal profile for the predetermined volume is indicated on the image of the prostate gland on the display based on the plurality of input parameters.

[0037] In many embodiments, the plurality of input parameters include one or more of a longitudinal distance of the removal profile, a radial distance of the removal profile, an angular distance of the removal profile about a longitudinal axis of the removal profile, an axis of the removal profile, a center position of the removal profile, or a user-defined input removal profile in response to a user moving a pointer over an image of the prostate.

[0038] In many embodiments, the images of the prostate include an axial view of the prostate and a sagittal view of the prostate, and an axial view of the predetermined tissue removal profile is shown on the axial view of the prostate and a sagittal view of the tissue removal profile is shown on the sagittal view of the prostate.

[0039] In many embodiments, the axial image of the predetermined removal profile is adjusted based on the radial and angular distances of the predetermined removal profile, and the axial image of the predetermined removal profile is adjusted based on the axial and radial distances of the predetermined removal profile.

[0040] In many embodiments, the tissue removal profile shown on the image of the prostate includes dimensions that are scaled to the image of the prostate shown on the display such that the dimensions of the tissue removal profile shown on the display correspond to the dimensions of the image of the prostate shown on the display.

[0041] In many embodiments, a treatment reference marker is shown along with an image of the prostate, and a tissue removal profile is shown on the display relative to the treatment reference marker based on a plurality of input parameters.

[0042] In many embodiments, the treatment reference markers shown on the display correspond to anchors connected to the energy source.

[0043] In many embodiments, the treatment reference marker shown on the display corresponds to an expandable anchor connected to the energy source, the expandable anchor including a first narrow profile configuration sized for insertion into the lumen and a second wide profile configuration for blocking passage through the lumen when positioned at the patient's bladder neck, and the treatment reference marker shown on the display includes an image of the expandable anchor in the wide profile configuration at the top of the image of the prostate gland.

[0044] In many embodiments, the image of the prostate shown on the display comprises an image of the patient's prostate, or an anatomical representation of the prostate suitable for use with multiple patients.

[0045] In many embodiments, the image of the patient's prostate gland shown on the display comprises a transrectal ultrasound image of the patient's prostate gland.

[0046] In many embodiments, a nozzle is identified from among a plurality of nozzles to treat a patient with a pressurized fluid stream based on the radial distance of a tissue removal profile input into a processor.

[0047] In many embodiments, the tissue is coagulated using a light beam at a radial and angular distance of a portion of the tissue removal profile after removal of the tissue using a pressurized fluid stream, the angular distance corresponding to a rear portion of the removal profile.

[0048] In many embodiments, the fluid stream comprises a diverging stream of a substantially incompressible fluid and the light beam comprises a diverging light beam.

[0049] In many embodiments, the treatment axis of the predetermined treatment volume is aligned with the axis of the patient based on an image of the prostate and the energy emitted radially from the probe.

[0050] In many embodiments, the axis of the predetermined volume includes an anterior-posterior axis of the treatment volume, which is aligned with the anterior-posterior direction of the patient based on visualization of the tissue and the angle of energy emitted from the probe to rotationally align the treatment energy emitted from the probe with the anterior-posterior direction of the patient.

[0051] In many embodiments, the images include ultrasound images showing one or more of tissue deflection or fluid flow in response to pressurized fluid being emitted from the nozzle, and the angle of the fluid flow about the elongated axis of the treatment probe is adjusted to align the treatment axis with the axis of the patient.

[0052] In many embodiments, the image includes an optical image showing a light beam emitted radially from the probe irradiating the tissue, the angle of the light beam about the elongated axis of the treatment probe being adjusted to align the treatment axis with the patient.

[0053] Many embodiments further include a processor, the processor including instructions for a user to adjust the angle of energy radially emitted from the treatment probe about the elongated axis of the treatment probe to align the radially emitted energy with the patient's axis, the processor including instructions for inputting an angle in response to a user command when the angle of the energy is aligned with the patient's axis, and the processor including instructions for rotating the treatment axis based on the angle input to the processor.

[0054] In many embodiments, an angular rotation sensor determines rotation of the treatment probe about the elongated axis of the probe relative to the axis of the patient, the treatment axis of the predetermined treatment volume is rotated in response to the rotation of the treatment probe, and the patient is positioned on the patient support so that the anterior-posterior direction of the patient is aligned with the direction of the gravitational force.

[0055] In many embodiments, the angular rotation sensor includes one or more of an accelerometer or a goniometer.

[0056] In another aspect, embodiments provide tissue ablation. A carrier has a proximal end and a distal end. At least one energy source on the carrier is spaced proximally so as to be positioned within the tissue when delivering energy radially outward. An automatic controller controls movement of the at least one energy source to achieve volumetric tissue removal.

[0057] In another aspect, embodiments provide a tissue ablation device for ablating tissue of an organ such as the prostate. The device includes a carrier having a proximal end and a distal end. At least one energy source on the carrier is spaced proximally so as to be positioned within the urethra when delivering energy radially outward. An automatic controller controls movement of the at least one energy source to achieve volumetric tissue removal.

[0058] In many embodiments, an automatic controller controls the movement of the energy source based on a pre-defined plan.

[0059] In many embodiments, the default plan is input by the user based on pre-operative images of the prostate.

[0060] In many embodiments, the automatic controller controls the movement of the energy source based on real-time assessment of the prostate gland obtained from an input device.

[0061] In many embodiments, the input device includes an interstitial laser-guided imaging device.

[0062] In many embodiments, the input device includes an interstitial laser-guided imaging device.

[0063] In many embodiments, the input device includes an interstitial sound-induced differential detector.

[0064] In many embodiments, the automatic controller further includes a pulse width modulation device.

[0065] Many embodiments further include means for the user to override the automatic controller.

[0066] Many embodiments further comprise: providing an image of the prostate on a display that is visible to a user; a processor including instructions configured to receive a plurality of input parameters corresponding to an axial length and a radial distance of a predetermined volume of tissue; A predetermined tissue removal profile of a predetermined volume is presented on the image of the prostate on the display based on a number of input parameters.

[0067] In many embodiments, the plurality of input parameters include one or more of a longitudinal distance of the removal profile, a radial distance of the removal profile, an angular distance of the removal profile about a longitudinal axis of the removal profile, an axis of the removal profile, a center position of the removal profile, or a user-defined input removal profile in response to a user moving a pointer over an image of the prostate.

[0068] In many embodiments, the images of the prostate include an axial view of the prostate and a sagittal view of the prostate, and an axial view of the predetermined tissue removal profile is shown on the axial view of the prostate and a sagittal view of the tissue removal profile is shown on the sagittal view of the prostate.

[0069] In many embodiments, the processor includes instructions for adjusting the axial image of the predetermined removal profile based on the radial distance and the angular distance of the predetermined removal profile, and the processor includes instructions for adjusting the axial image of the predetermined removal profile based on the axial distance and the radial distance of the predetermined removal profile.

[0070] In many embodiments, the tissue removal profile shown on the image of the prostate includes dimensions that are scaled to the image of the prostate shown on the display such that the dimensions of the tissue removal profile shown on the display correspond to the dimensions of the image of the prostate shown on the display.

[0071] In many embodiments, the processor includes instructions for presenting a treatment reference marker along with an image of the prostate, and for presenting a tissue removal profile on the display for the treatment reference marker based on a plurality of input parameters.

[0072] In many embodiments, the treatment reference markers shown on the display correspond to anchors connected to the energy source.

[0073] In many embodiments, the treatment reference marker shown on the display corresponds to an expandable anchor connected to the energy source, the expandable anchor including a first narrow profile configuration sized for insertion into the lumen and a second wide profile configuration for blocking passage through the lumen when positioned at the patient's bladder neck, and the treatment reference marker shown on the display includes an image of the expandable anchor in the wide profile configuration at the top of a sagittal image of the prostate.

[0074] In many embodiments, the treatment reference markers shown on the display include fixed treatment reference markers, and the processor includes instructions for showing the fixed reference markers and movable markers that move relative to the treatment profile to indicate the location of energy flow to the target tissue in real time.

[0075] In many embodiments, the movable marker is shown in a plurality of images, including sagittal images along the sagittal axis of treatment and axial images transverse to the treatment axis, the movable marker moves along the treatment axis in the sagittal images, the movable marker rotates around an axis in the axial images, and a fixed reference marker is displayed on each of the plurality of images relative to the movable marker.

[0076] In many embodiments, the image of the prostate shown on the display comprises an image of the patient's prostate, or an anatomical representation of the prostate suitable for use with multiple patients.

[0077] In many embodiments, the image of the patient's prostate gland shown on the display comprises a transrectal ultrasound image of the patient's prostate gland.

[0078] In many embodiments, the processor includes instructions for identifying a nozzle from among a plurality of nozzles that treats a patient with a pressurized fluid stream based on a radial distance of a tissue removal profile input into the processor.

[0079] In many embodiments, the processor includes instructions for coagulating tissue using the light beam at a radial and angular distance of a portion of the tissue removal profile after removal of the tissue using the pressurized fluid stream, the angular distance corresponding to a trailing portion of the removal profile.

[0080] In many embodiments, the fluid stream comprises a diverging stream of a substantially incompressible fluid and the light beam comprises a diverging light beam.

[0081] In many embodiments, the treatment axis of the predetermined treatment volume is aligned with the axis of the patient based on an image of the prostate and the energy emitted radially from the probe.

[0082] In many embodiments, the axis of the predetermined volume includes an anterior-posterior axis of the treatment volume, which is aligned with the anterior-posterior direction of the patient based on visualization of the tissue and the angle of energy emitted from the probe to rotationally align the treatment energy emitted from the probe with the anterior-posterior direction of the patient.

[0083] In many embodiments, the images include ultrasound images showing one or more of tissue deflection or fluid flow in response to pressurized fluid being emitted from the nozzle, and the angle of the fluid flow about the elongated axis of the treatment probe is adjusted to align the treatment axis with the axis of the patient.

[0084] In many embodiments, the image includes an optical image showing a light beam emitted radially from the probe irradiating the tissue, the angle of the light beam about the elongated axis of the treatment probe being adjusted to align the treatment axis with the patient.

[0085] Many embodiments further include a processor, the processor including instructions for a user to adjust the angle of energy radially emitted from the treatment probe about the elongated axis of the treatment probe to align the radially emitted energy with the patient's axis, the processor including instructions for inputting an angle in response to a user command when the angle of the energy is aligned with the patient's axis, and the processor including instructions for rotating the treatment axis based on the angle input to the processor.

[0086] In many embodiments, an angular rotation sensor determines rotation of the treatment probe about the elongated axis of the probe relative to the axis of the patient, the treatment axis of the predetermined treatment volume is rotated in response to the rotation of the treatment probe, and the patient is positioned on the patient support so that the anterior-posterior direction of the patient is aligned with the direction of the gravitational force.

[0087] In many embodiments, the angular rotation sensor includes one or more of an accelerometer or a goniometer.

[0088] Many embodiments further comprise: providing a plurality of images of the tissue on a display visible to a user, each image of the plurality of images including a plane of a three-dimensional representation of the tissue; receiving input from a user to define a treatment profile along each of the plurality of images; A processor including instructions configured to determine a three-dimensional treatment profile based on the treatment profile along each of the plurality of images.

[0089] In many embodiments, the processor includes instructions for interpolating between treatment profiles of the multiple images to determine a three-dimensional treatment profile.

[0090] Many embodiments further include a non-pulsating pump coupled to the carrier and the automatic controller to provide a pulsed energy flow comprising a plurality of successive pulses.

[0091] Many embodiments further include a pulsating pump coupled to the carrier and the automatic controller to provide a pulsed energy flow comprising a plurality of successive pulses.

[0092] In many embodiments, the automatic controller is configured to move the pulsed energy delivery stream so that multiple successive pulses overlap at the target location of the tissue to be ablated.

[0093] In many embodiments, the automatic controller is configured to shift the pulsed energy delivery stream so that multiple successive pulses do not overlap at the target location of the tissue to be ablated.

[0094] In another aspect, embodiments provide an apparatus for treating tissue of a patient. An elongated treatment probe for treating the patient extends along an axis. The elongated treatment probe includes an outer elongated structure having a working channel and an inner carrier rotatable and translatable within the working channel to position and orient an energy source to emit energy toward the target tissue. An elongated imaging probe extends along the axis. A coupler couples the elongated treatment probe to the elongated imaging probe when the elongated treatment probe and the elongated imaging probe are inserted into the patient.

[0095] Many embodiments further include a first linkage connected to the inner carrier and a second linkage connected to the imaging probe, and the one or more controllers are configured to move the first linkage together with the second linkage to move the inner carrier along the treatment axis and move the imaging probe along the imaging probe axis to visualize the carrier's interaction with the tissue as the carrier moves along the axes.

[0096] In many embodiments, the coupler comprises: A base and a first arm extending from the base and connected to a proximal end of the elongated treatment probe; a second arm extending from the base and connected to the proximal end of the elongated imaging probe; wherein the base supports the elongated treatment probe and the elongated imaging probe when the first arm includes a rigid configuration and the second arm includes a rigid configuration.

[0097] In many embodiments, the second arm includes an actuator for manipulating the imaging probe under user control while the first arm maintains the position and orientation of the elongated treatment probe.

[0098] In many embodiments, the coupling is configured to maintain alignment of the elongate treatment probe with respect to the elongate imaging probe when the elongate imaging probe and the elongate treatment probe are inserted from opposite sides of the patient.

[0099] In many embodiments, the coupler is configured to maintain alignment of the axis of the elongate treatment probe with the axis of the elongate imaging probe when the nozzle is advanced proximally and distally and rotated.

[0100] In many embodiments, the coupler is configured to align the axis of the treatment probe parallel to the axis of the imaging probe.

[0101] In many embodiments, the coupler is configured to maintain a fixed position and orientation of the elongate imaging probe relative to the elongate imaging probe.

[0102] In many embodiments, the coupler includes a rigid arm coupled to the elongated treatment probe and a second rigid arm coupled to the elongated imaging probe, the first rigid arm being fixedly coupled to the second rigid arm, the elongated treatment probe including rigidity to prevent deflection transverse to the treatment probe axis, and the elongated imaging probe including rigidity to prevent deflection transverse to the elongated imaging probe axis.

[0103] In many embodiments, the coupler includes a magnet for maintaining a fixed position and orientation of the elongate imaging probe relative to the elongate imaging probe.

[0104] In many embodiments, the coupler includes multiple magnets positioned at multiple axial positions along one or more of the elongate treatment probe or the elongate imaging probe.

[0105] In many embodiments, the coupler is configured to couple the elongated treatment probe to the elongated imaging probe through a wall of a first lumen extending over a portion of the elongated treatment probe and a wall of a second lumen extending over a portion of the elongated imaging probe.

[0106] In many embodiments, the elongated imaging probe is configured for insertion into the patient's rectum and the elongated treatment probe is configured for insertion into the patient's urethra, and the coupler is configured to align the elongated treatment probe with the elongated imaging probe when the elongated treatment probe is positioned in the urethra and when the elongated imaging probe is positioned in the rectum.

[0107] In many embodiments, the elongate structure includes a spine that adds stiffness to the probe such that the elongate structure resists deflection of the probe transversely to its axis.

[0108] In many embodiments, the elongate imaging probe includes at least a rigid distal portion to prevent deflection of the imaging probe transverse to the axis of the imaging probe and to fix the orientation of the axis of the elongate imaging probe relative to the axis of the elongate treatment probe.

[0109] In many embodiments, a processor is coupled to the elongated imaging probe, the elongated treatment probe, and the linkage, and the processor includes instructions for determining the pressure, axial location, and orientation of the nozzle for ablating a target location of tissue identified on an image of the elongated imaging probe.

[0110] In many embodiments, the processor includes instructions for determining the pressure, axial location and orientation of the nozzle in response to a target location on an image when the elongated treatment probe is inserted on a first side of the patient and the elongated imaging probe is inserted on a second side opposite the first side of the patient.

[0111] In many embodiments, the processor includes instructions for determining the pressure, axial location and orientation of the nozzle in response to a target location on the image when the elongated treatment probe is coupled to the elongated imaging probe through a wall of a first lumen and a wall of a second lumen extending between the elongated treatment probe and the elongated imaging probe.

[0112] In many embodiments, the processor includes instructions for determining a first image coordinate reference of a first input target location of the image and a second image coordinate reference of a second input target location of the image, and instructions for mapping the first image coordinate reference of the image to a first target coordinate reference of the treatment probe and mapping the second input target location of the image to a second target coordinate reference of the treatment probe, and the processor includes instructions for determining the pressure and axial and rotational positions of the nozzle to provide a cutting profile extending from the first input target location to the second input target location.

[0113] In another aspect, embodiments provide an apparatus for treating tissue of a patient. An arm is coupled to a base. The arm includes a first movable configuration and a second rigid configuration. A treatment probe for treating a patient includes an outer elongated structure having a working channel and an inner carrier rotatable and translatable within the working channel to position and orient a nozzle to emit a pressurized flow toward the tissue. A processor includes instructions for rotating and translating the carrier to treat the patient. A linkage is coupled to the processor to rotate and translate the probe in response to the instructions.

[0114] In many embodiments, the carrier includes a rapid exchange carrier configured to be inserted and removed from the proximal end of the outer elongate structure, the linkage including a rotatable and translatable elongate linkage tube having an inner dimension sized to receive the inner carrier, and the elongate linkage tube including a locking structure for locking the rapid exchange carrier within the elongate linkage tube when the elongate linkage tube rotates and translates to treat tissue.

[0115] Many embodiments further include a manifold and a plurality of channels, the manifold connected to the proximal end of the outer elongate structure, the plurality of channels extending along the outer elongate structure for coupling a first port of the manifold to a balloon anchor using a first channel and for coupling a second port of the manifold to an opening near the distal end of the outer elongate structure for delivering fluid to the treatment site, the manifold including a locking structure, and the linkage including a locking structure for connecting the linkage to the manifold when the balloon is inflated.

[0116] In many embodiments, the elongate structure includes a spine coupled to the anchor, the spine extending between the anchor and the linkage to fix the distance from the first part of the linkage to the anchor when the probe's carrier is rotated and translated with the second part of the linkage to position and orient the nozzle to treat a target location of a patient referenced to the anchor.

[0117] In many embodiments, the elongate structure is coupled to the anchor and extends between the anchor and the linkage to fix the distance along the elongate structure from the first portion of the linkage to the anchor when the carrier is rotated and translated with the second portion of the linkage to position and orient the nozzle to treat a patient.

[0118] In many embodiments, the elongate structure and carrier are configured to deflect when the probe is inserted into tissue, and the elongate structure maintains a substantially constant arc length between the fixed position of the linkage and the anchor to maintain alignment of the nozzle relative to the anchor when the nozzle is rotated and translated along the probe axis with the carrier to treat a patient.

[0119] In many embodiments, the linkage includes an outer handpiece portion that is graspable and positionable with a user's hand when the arms include an unlocked configuration.

[0120] In many embodiments, the linkage includes a support coupled to the treatment probe and the arm such that the arm is used to support the treatment probe and the linkage when the probe is inserted into a patient.

[0121] In many embodiments, the support comprises one or more of a rigid casing of the linkage or a frame of the linkage, the casing remaining substantially fixed relative to the arm when the patient is treated.

[0122] In many embodiments, a support is coupled to the treatment probe to insert the probe into the patient and position the nozzle at the target location and orientation, and when the arm comprises a rigid configuration, the support is coupled to the arm and elongated structure to support the probe while it is positioned and oriented within the patient.

[0123] In many embodiments, the support and arm are capable of supporting the linkage and probe in an intended position and orientation, where the arm includes a rigid configuration to fix the location of the linkage when a patient is treated with the nozzle.

[0124] In many embodiments, the probe includes an elongated structure and an inner carrier, and a linkage is coupled to the carrier to control the position of the nozzle along the axis of the elongated structure and the rotation of the nozzle about the axis of the elongated structure.

[0125] In many embodiments, the device is configured to remove viable cells from tissue to provide viable cells outside the patient.

[0126] In many embodiments, the device is configured to remove tissue for histology.

[0127] In many embodiments, the device is configured to macerate tissue.

[0128] In many embodiments, the device is configured to emit a high-pressure fluid stream into a gas that includes carbon dioxide (hereinafter "CO2").

[0129] In many embodiments, the device includes an optical fiber having a bend radius of about 5 mm or less.

[0130] In many embodiments, the device includes an optical fiber having a bend radius of about 2 mm or less.

[0131] Although embodiments of the present invention are specifically directed to the transurethral treatment of the prostate, certain aspects of the present invention may also be used to treat and modify other organs such as the brain, heart, lungs, intestines, eyes, skin, kidneys, liver, pancreas, stomach, uterus, ovaries, testes, bladder, ears, nose, mouth, bone marrow, fatty tissue, muscle, glandular and mucosal tissue, spinal cord and nerve tissue, soft tissue such as cartilage, hard tissue such as teeth, bone, and body lumens and passageways such as the sinuses, ureters, colon, esophagus, pulmonary passageways, blood vessels, and throat. The devices disclosed herein may be inserted through existing body lumens or through openings created in body tissue. The present invention provides, for example, the following. (Item 1) 1. A method for tissue ablation, the method comprising: Locating energy sources within the organization and directing energy radially outward from the energy source toward the tissue; moving the energy source to remove a predetermined volume of tissue, the movement of the energy source being controlled at least in part by an automatic controller; A method comprising: (Item 2) 1. A method for prostate tissue ablation, said method comprising: positioning an energy source within a urethra having a lumen; directing energy from the energy source radially outward toward a wall of the urethra within the prostate; moving the energy source to remove a predetermined volume of tissue surrounding the lumen, the movement of the energy source being controlled at least in part by an automatic controller; A method comprising: (Item 3) 3. The method according to claim 2, wherein the automatic controller controls the movement of the energy source based on a predetermined plan. (Item 4) 3. The method according to claim 2, wherein the automatic controller controls the movement of the energy source based on a predetermined plan. (Item 5) 3. The method of claim 2, wherein the predetermined plan is input by a user based on preoperative images of the prostate. (Item 6) 3. The method of claim 2, wherein the automatic controller controls the movement of the energy source based on a real-time assessment of the prostate. (Item 7) 7. The method of claim 6, wherein the real-time assessment comprises interstitial laser-guided imaging. (Item 8) 7. The method of claim 6, wherein the real-time assessment comprises acoustic distance measurement. (Item 9) 7. The method of claim 6, wherein the real-time assessment comprises interstitial sound-guided differentiation. (Item 10) 7. The method of claim 6, wherein the automatic control further comprises pulse width modulation. (Item 11) 3. The method of claim 2, further comprising a user disabling the automatic control. (Item 12) providing an image of the prostate on a display coupled to the processor, the display being viewable by a user; receiving a plurality of input parameters corresponding to an axial length and a radial distance of the predetermined volume of tissue; wherein the predetermined volume of predetermined tissue removal profile is indicated on the image of the prostate on the display based on the plurality of input parameters. The method described in item 2. (Item 13) Item 13. The method of item 12, wherein the plurality of input parameters include one or more of a longitudinal distance of the removal profile, a radial distance of the removal profile, an angular distance of the removal profile around a longitudinal axis of the removal profile, an axis of the removal profile, a center position of the removal profile, or a user-defined input removal profile in response to the user moving a pointer over the image of the prostate. (Item 14) Item 14. The method of item 13, wherein the images of the prostate include an axial image of the prostate and a sagittal image of the prostate, and wherein an axial image of the predetermined tissue removal profile is shown on the axial image of the prostate and a sagittal image of the tissue removal profile is shown on the sagittal image of the prostate. (Item 15) Item 15. The method of item 14, wherein the axial image of the predetermined removal profile is adjusted based on the radial distance and the angular distance of the predetermined removal profile, and the axial image of the predetermined removal profile is adjusted based on the axial distance and the radial distance of the predetermined removal profile. (Item 16) Item 13. The method of item 12, wherein the tissue removal profile shown on the image of the prostate includes dimensions that are scaled to the image of the prostate shown on the display such that dimensions of the tissue removal profile shown on the display correspond to dimensions of the image of the prostate shown on the display. (Item 17) 13. The method of claim 12, wherein a treatment reference marker is shown together with the image of the prostate, and the tissue removal profile is shown on the display relative to the treatment reference marker based on the plurality of input parameters. (Item 18) 18. The method of claim 17, wherein the therapeutic reference marker shown on the display corresponds to an anchor connected to the energy source. (Item 19) Item 18. The method of item 17, wherein the treatment reference marker shown on the display corresponds to an expandable anchor connected to the energy source, the expandable anchor including a first narrow profile configuration sized for insertion into the lumen and a second wide profile configuration for blocking passage through the lumen when positioned at the patient's bladder neck, and the treatment reference marker shown on the display includes an image of the expandable anchor in its wide profile configuration at an upper edge of the image of the prostate. (Item 20) 13. The method of claim 12, wherein the image of the prostate shown on the display comprises an image of the prostate of the patient, or an anatomical representation of the prostate suitable for use with multiple patients. (Item 21) 21. The method of claim 20, wherein the image of the prostate gland of the patient shown on the display comprises a transrectal ultrasound image of the prostate gland of the patient. (Item 22) 13. The method of claim 12, wherein a nozzle is identified from among a plurality of nozzles for treating the patient with a pressurized fluid stream based on a radial distance of the tissue removal profile input into the processor. (Item 23) 23. The method of claim 22, wherein the tissue is coagulated using a light beam at a radial and angular distance of a portion of the tissue removal profile after removal of the tissue with the pressurized fluid stream, the angular distance corresponding to a rear portion of the removal profile. (Item 24) Item 24. The method of item 23, wherein the fluid stream comprises a diverging stream of a substantially incompressible fluid and the light beam comprises a diverging light beam. (Item 25) 3. The method of claim 2, wherein a treatment axis of the predetermined treatment volume is aligned with an axis of the patient based on an image of the prostate and energy emitted radially from a probe. (Item 26) 26. The method of claim 25, wherein the axis of the predetermined volume comprises an anterior-posterior axis of the treatment volume, and the anterior-posterior axis of the treatment volume is aligned with the anterior-posterior direction of the patient based on the visualization of the tissue and an angle of energy emitted radially from the probe to rotationally align the treatment energy emitted from the probe with the anterior-posterior direction of the patient. (Item 27) 27. The method of claim 26, wherein the images include ultrasound images showing one or more of the tissue deflection or fluid flow in response to pressurized fluid being discharged from a nozzle, and an angle of the fluid flow about an elongated axis of a treatment probe is adjusted to align the treatment axis with the axis of the patient. (Item 28) 27. The method of claim 26, wherein the image comprises an optical image showing a light beam emitted radially from the probe irradiating the tissue, and an angle of the light beam about an elongated axis of the treatment probe is adjusted to align the treatment axis with the patient. (Item 29) 27. The method of claim 26, further comprising a processor, wherein the processor includes instructions for the user to adjust an angle of the energy radially emitted from the treatment probe about an elongated axis of the treatment probe to align the radially emitted energy with an axis of the patient, the processor includes instructions for inputting the angle in response to a user command when the angle of the energy is aligned with the axis of the patient, and the processor includes instructions for rotating the treatment axis based on the angle input to the processor. (Item 30) Item 26. The method of item 25, wherein an angular rotation sensor determines a rotation of the treatment probe about an elongated axis of the probe relative to an axis of the patient, a treatment axis of the predetermined treatment volume is rotated in response to the rotation of the treatment probe, and the patient is positioned on a patient support such that an anterior-posterior direction of the patient is aligned with a direction of gravitational force. (Item 31) Item 31. The method of item 30, wherein the angular rotation sensor includes one or more of an accelerometer or a goniometer. (Item 32) a carrier having a proximal end and a distal end; at least one energy source on the carrier spaced proximally to be positioned at tissue when delivering energy radially outward; an automatic controller for controlling movement of said at least one energy source to achieve volumetric tissue removal; 1. A tissue ablation device comprising: (Item 33) a carrier having a proximal end and a distal end; at least one energy source on the carrier spaced proximally so as to be positioned at the urethra when delivering energy radially outward; an automatic controller for controlling movement of said at least one energy source to achieve volumetric tissue removal; 1. A prostatectomy device comprising: (Item 34) Item 34. The apparatus of item 33, wherein the automatic controller controls the movement of the energy source based on a predetermined plan. (Item 35) Item 35. The apparatus of item 34, wherein the predetermined plan is input by a user based on preoperative images of the prostate. (Item 36) 34. The apparatus of claim 33, wherein the automatic controller controls movement of the energy source based on real-time assessment of the prostate obtained from an input device. (Item 37) Item 37. The apparatus of item 36, wherein the input device includes an interstitial laser-guided imaging device. (Item 38) Item 37. The apparatus of item 36, wherein the input device includes an interstitial laser-guided imaging device. (Item 39) Item 37. The apparatus of item 36, wherein the input device includes an interstitial sound-induced difference detector. (Item 40) Item 37. The apparatus of item 36, wherein the automatic controller further includes a pulse width modulation device. . (Item 41) Item 37. The apparatus of item 36, further comprising means for the user to override the automatic controller. (Item 42) providing an image of the prostate on a display that is visible to a user; receiving a plurality of input parameters corresponding to an axial length and a radial distance of the predetermined volume of tissue; and a processor including instructions configured to: a predetermined volume of tissue removal profile is shown on the image of the prostate on the display based on the plurality of input parameters. Item 34. The device according to item 33. (Item 43) Item 43. The apparatus of item 42, wherein the plurality of input parameters include one or more of a longitudinal distance of the removal profile, a radial distance of the removal profile, an angular distance of the removal profile around a longitudinal axis of the removal profile, an axis of the removal profile, a center position of the removal profile, or a user-defined input removal profile in response to the user moving a pointer over the image of the prostate. (Item 44) Item 44. The apparatus of item 43, wherein the images of the prostate include an axial image of the prostate and a sagittal image of the prostate, and wherein an axial image of the predetermined tissue removal profile is shown on the axial image of the prostate and a sagittal image of the tissue removal profile is shown on the sagittal image of the prostate. (Item 45) Item 45. The apparatus of item 44, wherein the processor includes instructions for adjusting the axial image of the predetermined removal profile based on the radial distance and the angular distance of the predetermined removal profile, and the processor includes instructions for adjusting the axial image of the predetermined removal profile based on the axial distance and the radial distance of the predetermined removal profile. (Item 46) Item 43. The device of item 42, wherein the tissue removal profile shown on the image of the prostate includes dimensions that are scaled to the image of the prostate shown on the display such that the dimensions of the tissue removal profile shown on the display correspond to the dimensions of the image of the prostate shown on the display. (Item 47) 43. The device of claim 42, wherein the processor includes instructions for displaying a treatment reference marker together with the image of the prostate, and for displaying the tissue removal profile on the display relative to the treatment reference marker based on the plurality of input parameters. (Item 48) Item 48. The device of item 47, wherein the treatment reference marker shown on the display corresponds to an anchor connected to the energy source. (Item 49) Item 48. The device of item 47, wherein the treatment reference marker shown on the display corresponds to an expandable anchor connected to the energy source, the expandable anchor including a first narrow profile configuration sized for insertion into the lumen and a second wide profile configuration for blocking passage through the lumen when positioned at the patient's bladder neck, and the treatment reference marker shown on the display includes an image of the expandable anchor in its wide profile configuration at the top of a sagittal image of the prostate. (Item 50) Item 48. The device of item 47, wherein the treatment reference marker shown on the display includes a fixed treatment reference marker, and the processor includes instructions for showing a movable marker that moves relative to the fixed reference marker and the treatment profile to indicate the location of energy flow to the target tissue in real time. (Item 51) The movable marker is a plurality of images, including a sagittal image along a sagittal axis of treatment and an axial image transverse to the treatment axis; wherein the movable marker moves along the treatment axis in the sagittal images, the movable marker rotates about the axis in the axial images, and the fixed reference marker is displayed on each of the plurality of images relative to the movable marker. (Item 52) 43. The apparatus of claim 42, wherein the image of the prostate shown on the display comprises an image of the prostate of the patient, or an anatomical representation of the prostate suitable for use with multiple patients. (Item 53) Item 53. The apparatus of item 52, wherein the image of the prostate gland of the patient shown on the display comprises a transrectal ultrasound image of the prostate gland of the patient. (Item 54) Item 43. The apparatus of item 42, wherein the processor includes instructions for identifying a nozzle from among a plurality of nozzles for treating the patient with a pressurized fluid stream based on a radial distance of the tissue removal profile input into the processor. (Item 55) 55. The apparatus of claim 54, wherein the processor includes instructions for coagulating tissue with a light beam at a radial and angular distance of a portion of the tissue removal profile after removal of the tissue with the pressurized fluid stream, the angular distance corresponding to a rear portion of the removal profile. (Item 56) Item 56. The apparatus of item 55, wherein the fluid stream comprises a diverging stream of a substantially incompressible fluid and the light beam comprises a diverging light beam. (Item 57) Item 43. The apparatus of item 42, wherein a treatment axis of the predetermined treatment volume is aligned with an axis of the patient based on the image of the prostate and energy emitted radially from a probe. (Item 58) Item 58. The apparatus of item 57, wherein the axis of the predetermined volume includes an anterior-posterior axis of the treatment volume, and the anterior-posterior axis of the treatment volume is aligned with the anterior-posterior direction of the patient based on visualization of the tissue and an angle of energy emitted radially from the probe to rotationally align the treatment energy emitted from the probe with the anterior-posterior direction of the patient. (Item 59) Item 59. The apparatus of item 58, wherein the images include ultrasound images showing one or more of the tissue deflection or fluid flow in response to pressurized fluid being emitted from a nozzle, and the angle of the fluid flow about an elongated axis of a treatment probe is adjusted to align the treatment axis with the axis of the patient. (Item 60) Item 59. The apparatus of item 58, wherein the image comprises an optical image showing a light beam emitted radially from the probe irradiating the tissue, and an angle of the light beam about an elongated axis of the treatment probe is adjusted to align the treatment axis with the patient. (Item 61) 59. The apparatus of claim 58, further comprising a processor, wherein the processor includes instructions for the user to adjust the angle of the energy radially emitted from the treatment probe about the elongated axis of the treatment probe to align the radially emitted energy with the axis of the patient, the processor includes instructions for inputting the angle in response to a user command when the angle of the energy is aligned with the axis of the patient, and the processor includes instructions for rotating the treatment axis based on the angle input to the processor. (Item 62) Item 58. The apparatus of item 57, wherein an angular rotation sensor determines rotation of the treatment probe about the elongated axis of the probe relative to the axis of the patient, wherein the treatment axis of the predetermined treatment volume is rotated in response to the rotation of the treatment probe, and wherein the patient is positioned on a patient support such that the anterior-posterior direction of the patient is aligned with the direction of the gravitational force. (Item 63) Item 63. The apparatus of item 62, wherein the angular rotation sensor includes one or more of an accelerometer or a goniometer. (Item 64) providing a plurality of images of tissue on a display visible to a user, each image of the plurality of images comprising a plane of a three-dimensional representation of tissue; receiving input from the user to define a treatment profile along each of the images of the plurality of images; determining a three-dimensional treatment profile based on the treatment profile along each of the images of the plurality of images; Item 34. The apparatus of item 33, further comprising a processor comprising instructions configured to: (Item 65) Item 65. The apparatus of item 64, wherein the processor includes instructions for interpolating between treatment profiles of the plurality of images to determine the three-dimensional treatment profile. (Item 66) 34. The apparatus of claim 33, further comprising a non-pulsating pump coupled to the carrier and the automatic controller to provide a pulsed energy flow comprising a plurality of successive pulses. (Item 67) 34. The apparatus of claim 33, further comprising a pulsating pump coupled to the carrier and the automatic controller to provide a pulsed energy flow comprising a plurality of successive pulses. (Item 68) Item 68. The apparatus of item 67, wherein the automatic controller is configured to move the pulsed energy delivery stream so that the multiple consecutive pulses overlap at a target location of tissue to be ablated. (Item 69) Item 68. The apparatus of item 67, wherein the automatic controller is configured to move the pulsed energy delivery stream such that the multiple consecutive pulses do not overlap at the target location of the tissue to be ablated. (Item 70) 1. A device for treating tissue of a patient, the device comprising: an elongated treatment probe for treating a patient, the elongated treatment probe including: an outer elongated structure extending along an axis and having a working channel; and an inner carrier rotatable and translatable within the working channel to position and orient an energy source to emit energy toward a target tissue; an elongated imaging probe extending along an axis; a coupler for coupling the elongated treatment probe to the elongated imaging probe when the elongated treatment probe and the elongated imaging probe are inserted into the patient; 1. An apparatus comprising: (Item 71) Item 71. The device of item 70, further comprising a first linkage connected to the inner carrier and a second linkage connected to the imaging probe, wherein one or more controllers are configured to move the inner carrier along a treatment axis and move the imaging probe along an imaging probe axis by moving the first linkage together with the second linkage to visualize the carrier's interaction with tissue as the carrier moves along the axis. (Item 72) The coupler comprises: A base and a first arm extending from the base and connected to a proximal end of the elongated treatment probe; a second arm extending from the base and connected to the proximal end of the elongated imaging probe; Including, the base supports the elongate treatment probe and the elongate imaging probe when the first arm includes a rigid configuration and when the second arm includes a rigid configuration. Item 71. The device according to item 70. (Item 73) Item 74. The apparatus of item 73, wherein the second arm includes an actuator for manipulating the imaging probe under user control while the first arm maintains the position and orientation of the elongated treatment probe. (Item 74) Item 71. The apparatus of item 70, wherein the coupling portion is configured to maintain alignment of the elongate imaging probe with respect to the elongate treatment probe when the elongate imaging probe and the elongate treatment probe are inserted from opposite sides of the patient. (Item 75) Item 71. The device of item 70, wherein the coupler is configured to maintain alignment of the axis of the elongate treatment probe with the axis of the elongate imaging probe when the nozzle is advanced proximally and distally and rotated. (Item 76) Item 76. The apparatus of item 75, wherein the coupler is configured to align the axis of the treatment probe parallel to the axis of the imaging probe. (Item 77) Item 71. The apparatus of item 70, wherein the coupler is configured to maintain a fixed position and orientation of the elongate imaging probe relative to the elongate imaging probe. (Item 78) Item 71. The device described in Item 70, wherein the coupler includes a rigid arm coupled to the elongated treatment probe and a second rigid arm coupled to the elongated imaging probe, the first rigid arm being fixedly coupled to the second rigid arm, the elongated treatment probe including rigidity to prevent deflection transverse to the treatment probe axis, and the elongated imaging probe including rigidity to prevent deflection transverse to the elongated imaging probe axis. (Item 79) Item 71. The apparatus of item 70, wherein the coupler includes a magnet for maintaining a fixed position and orientation of the elongate imaging probe relative to the elongate imaging probe. (Item 80) Item 71. The apparatus of item 70, wherein the coupler includes a plurality of magnets positioned at a plurality of axial positions along one or more of the elongated treatment probe or the elongated imaging probe. (Item 81) Item 71. The device of item 70, wherein the coupler is configured to couple the elongated treatment probe to the elongated imaging probe through a wall of a first lumen extending over a portion of the elongated treatment probe and a wall of a second lumen extending over a portion of the elongated imaging probe. (Item 82) Item 71. The device of item 70, wherein the elongated imaging probe is configured for insertion into the patient's rectum and the elongated treatment probe is configured for insertion into the patient's urethra, and the coupler is configured to align the elongated treatment probe with the elongated imaging probe when the elongated treatment probe is positioned within the urethra and when the elongated imaging probe is positioned within the rectum. (Item 83) Item 71. The apparatus of item 70, wherein the elongate structure includes a spine that adds stiffness to the probe such that the elongate structure resists deflection of the probe transverse to the axis. (Item 84) Item 71. The apparatus of item 70, wherein the elongated imaging probe includes at least a rigid distal portion for preventing deflection of the imaging probe transverse to the axis of the imaging probe and for fixing the orientation of the axis of the elongated imaging probe relative to the axis of the elongated treatment probe. (Item 85) Item 71. The device of item 70, further comprising a processor coupled to the elongated imaging probe, the elongated treatment probe, and the linkage, the processor including instructions for determining the pressure, axial location, and orientation of the nozzle for ablating a target location of the tissue identified on an image of the elongated imaging probe. (Item 86) Item 86. The apparatus of item 85, wherein the processor includes instructions for determining the pressure, the axial location and orientation of the nozzle in response to the target location on the image when the elongated treatment probe is inserted on a first side of the patient and the elongated imaging probe is inserted on a second side opposite the one side of the patient. (Item 87) Item 86. The apparatus of item 85, wherein the processor includes instructions for determining the pressure, the axial location and orientation of the nozzle in response to the target location on the image when the elongated treatment probe is coupled to the elongated imaging probe through a wall of a first lumen and a wall of a second lumen extending between the elongated treatment probe and the elongated imaging probe. (Item 88) Item 86. The apparatus of item 85, wherein the processor includes instructions for determining a first image coordinate reference of a first input target location of the image and a second image coordinate reference of a second input target location of the image, and instructions for mapping the first image coordinate reference of the image to a first target coordinate reference of the treatment probe and mapping the second input target location of the image to a second target coordinate reference of the treatment probe, and the processor includes instructions for determining a pressure and an axial and rotational position of the nozzle to provide a cutting profile extending from the first input target location to the second input target location. (Item 89) 1. A device for treating tissue of a patient, the device comprising: an arm coupled to the base, the arm including a first movable configuration and a second rigid configuration; a treatment probe for treating a patient, the probe including: an outer elongated structure having a working channel; and an inner carrier rotatable and translatable within the working channel to position and orient a nozzle to thereby emit a pressurized flow toward the tissue; a processor containing instructions for rotating and translating the carrier to treat the patient; a linkage coupled to the processor and the probe for rotating and translating the probe in response to the commands; 1. An apparatus comprising: (Item 90) Item 90. The device of item 89, wherein the carrier includes a rapid exchange carrier configured to be inserted and removed from the proximal end of the outer elongate structure, the linkage includes a rotatable and translatable elongate linkage tube having an inner dimension sized to receive the inner carrier, the elongate linkage tube including a locking structure for locking the rapid exchange carrier within the elongate linkage tube when the elongate linkage tube rotates and translates to treat tissue. (Item 91) Item 90. The device of item 89, further comprising a manifold and a plurality of channels, the manifold connected to a proximal end of the outer elongate structure, the plurality of channels extending along the outer elongate structure for coupling a first port of the manifold to a balloon anchor using a first channel and for coupling a second port of the manifold to an opening near a distal end of the outer elongate structure for delivering fluid to a treatment site, the manifold including a locking structure, and the linkage including a locking structure for connecting the linkage to the manifold when the balloon is inflated. (Item 92) Item 90. The device of item 89, wherein the elongated structure includes a spine coupled to an anchor, the spine extending between the anchor and the linkage to fix the distance from the first part of the linkage to the anchor when the carrier of the probe is rotated and translated with the second part of the linkage to position and orient the nozzle to treat the target location of the patient referenced to the anchor. (Item 93) Item 90. The device of item 89, wherein the elongated structure is coupled to an anchor, and the elongated structure extends between the anchor and the linkage to fix the distance along the elongated structure from the first portion of the linkage to the anchor when the carrier is rotated and translated with the second portion of the linkage to position and orient the nozzle to treat the patient. (Item 94) Item 94. The device of item 93, wherein the elongated structure and the carrier are configured to deflect when the probe is inserted into the tissue, and the elongated structure maintains a substantially constant arc length between the fixed position of the linkage and the anchor to maintain alignment of the nozzle with respect to the anchor when the nozzle is rotated and translated along the probe axis with the carrier to treat the patient. (Item 95) Item 90. The device of item 89, wherein the linkage includes an outer handpiece portion that is graspable and positionable using the user's hand when the arm includes an unlocked configuration. (Item 96) 90. The apparatus of claim 89, wherein the linkage includes a support coupled to the treatment probe and the arm such that the arm is used to support the treatment probe and the linkage when the probe is inserted into the patient. (Item 97) Item 97. The device of item 96, wherein the support comprises one or more of a rigid casing of the linkage or a frame of the linkage, the casing remaining substantially fixed relative to the arm when the patient is treated. (Item 98) Item 97. The device of item 96, wherein the support is coupled to the treatment probe to insert the probe into the patient and position the nozzle at a target location and orientation, and the support is coupled to the arm and the elongated structure when the arm comprises the rigid configuration to support the probe with the probe positioned and oriented within the patient. (Item 99) Item 97. The device of item 96, wherein the support and the arm are capable of supporting the linkage and the probe in an intended position and orientation when the arm includes the rigid configuration to fix the location of the linkage when the patient is treated with the nozzle. (Item 100) Item 90. The apparatus of item 89, wherein the probe includes an elongated structure and an inner carrier, the linkage coupled to the carrier to control the position of the nozzle along an axis of the elongated structure and the rotation of the nozzle about the axis of the elongated structure. (Item 101) 10. The device of any preceding claim, wherein the device is configured to remove viable cells from the tissue to provide viable cells outside the patient. (Item 102) 10. The device of any preceding item, wherein the device is configured to remove tissue for histology. (Item 103) 104. The method of claim 102, wherein the device is configured to macerate the tissue. 10. The apparatus of claim 1, wherein the apparatus is configured to emit a high-pressure fluid stream into a gas containing CO2. (Item 105) 10. The device of claim 1, wherein the device includes an optical fiber having a bend radius of about 5 mm or less. (Item 106) 10. The device of any preceding item, wherein the device includes an optical fiber having a bend radius of about 2 mm or less. [Brief explanation of the drawings]

[0132] A better understanding of the features and advantages of the present disclosure will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the disclosure are utilized, and the accompanying drawings of which:

[0133] [Figure 1] FIG. 1 is a schematic diagram of a device suitable for performing intraurethral prostate tissue debulking in accordance with the principles of the present invention.

[0134] [Figure 2A] 2A-2D illustrate the use of the device of FIG. 1 in performing prostate tissue debulking surgery. [Figure 2B] 2A-2D illustrate the use of the device of FIG. 1 in performing prostate tissue debulking surgery. [Figure 2C] 2A-2D illustrate the use of the device of FIG. 1 in performing prostate tissue debulking surgery. [Figure 2D] 2A-2D illustrate the use of the device of FIG. 1 in performing prostate tissue debulking surgery.

[0135] [Figure 3]FIG. 3 illustrates a particular prostate tissue treatment device that incorporates the use of radiofrequency saline plasma to perform prostate tissue debulking.

[0136] [Figure 4] FIG. 4 illustrates an energy source suitable for use in the devices of the present invention, where the energy source delivers a fluid stream for tissue ablation.

[0137] [Figure 5] FIG. 5 illustrates an energy source suitable for use in the devices of the present invention, where the energy source includes a deflecting optical waveguide for delivering laser energy to prostate tissue.

[0138] [Figure 6] FIG. 6 illustrates a device similar to that shown in FIG. 5, except that an optical waveguide directs laser energy to a mirror that deflects the laser energy laterally.

[0139] [Figure 7] FIG. 7 illustrates an energy source suitable for use in the devices of the present invention, in which the energy source includes laterally protruding electrodes that can engage the urethral wall and prostate tissue to deliver radiofrequency energy for tissue ablation.

[0140] [Figure 8] FIG. 8 is a graph of tissue ablation rate demonstrating the critical pressure.

[0141] [Figure 9a] FIG. 9a is a flow diagram illustrating selective controlled ablation.

[0142] [Figure 9b] FIG. 9b is a flow diagram illustrating selective ablation in which the fluid stream is configured to penetrate the urethral wall before ablating the prostate tissue.

[0143] [Figure 10a]FIG. 10a illustrates a columnar and diverging fluid flow.

[0144] [Figure 10b] FIG. 10b illustrates a cross-sectional view of a tissue modification device configured to emit a columnar fluid stream.

[0145] [Figure 10c] FIG. 10c illustrates a cross-sectional view of a tissue modification device configured to emit diverging fluid flows.

[0146] [Figure 11] FIG. 11 illustrates a tissue modification device that uses a fluid flow for tissue ablation, where the fluid flow can optionally act as a conduit for electromagnetic energy.

[0147] [Figure 12] FIG. 12 shows components of a treatment probe 350, according to an embodiment.

[0148] [Figure 13A] 13A and 13B show a system for treating a patient, according to an embodiment. [Figure 13B] 13A and 13B show a system for treating a patient, according to an embodiment.

[0149] [Figure 14A] FIG. 14A shows a multi-purpose sheath and manifold, according to an embodiment.

[0150] [Figure 14B] FIG. 14B shows manifold conduits of a manifold such as that of FIG. 14A configured for the transmission and reception of multiple fluids while the manifold remains coupled to a patient, according to an embodiment.

[0151] [Figure 14C] FIG. 14C shows components of a treatment probe and linkage, according to an embodiment.

[0152] [Figure 14D1] FIG. 14D1 illustrates rapid exchange of a carrier when a link is coupled to an elongate element anchored to a target location in an organ, according to an embodiment.

[0153] [Figure 14D2] FIG. 14D2 shows the alignment of the distal tip of the carrier with the proximal end of the linkage for insertion of a carrier tube as in FIG. 14D1.

[0154] [Figure 14D3] FIG. 14D3 shows the carrier advanced towards the locking structure on the proximal end of the linkage as in FIG. 14D1.

[0155] [Figure 14D4] FIG. 14D4 shows a carrier locked to a link like those of FIGS. 14D1 and 14D2.

[0156] [Figure 14E] FIG. 14E shows a cystoscope at least partially inserted into an elongate element for advancement toward the bladder neck to visualize tissue of an organ such as the prostate, according to an embodiment.

[0157] [Figure 14F] FIG. 14F shows the advancement of the elongate element into the sheath.

[0158] [Figure 14G] FIG. 14G shows a linkage coupled to an elongate element including a spine, according to an embodiment.

[0159] [Figure 14H] FIG. 14H shows a carrier tube and carrier inserted into a chain tube, according to an embodiment.

[0160] [Figure 15] 15 and 16 show self-cleaning with a fluid jet, according to an embodiment. [Figure 16] 15 and 16 show self-cleaning with a fluid jet, according to an embodiment.

[0161] [Figure 17A] FIG. 17A illustrates components of a user interface on a display of a patient treatment system such as that of FIG. 13, according to an embodiment.

[0162] [Figure 17B] 17B and 17C show a marker moving across multiple images, where the movement of the marker corresponds to the position and orientation of the energy flow, according to an embodiment. [Figure 17C] 17B and 17C show a marker moving across multiple images, where the movement of the marker corresponds to the position and orientation of the energy flow, according to an embodiment.

[0163] [Figure 17D] FIG. 17D illustrates a user-defined cutting profile, according to an embodiment.

[0164] [Figure 17E] 17E and 17F show a user interface for defining multiple curved portions of a cutting profile, according to an embodiment. [Figure 17F] 17E and 17F show a user interface for defining multiple curved portions of a cutting profile, according to an embodiment.

[0165] [Figure 18] FIG. 18 shows the system configuration mode for disconnect mode entry of a user interface such as that of FIG. 17A.

[0166] [Figure 19] FIG. 19 shows the coagulation mode selected by inputting a user interface such as FIG. 17A.

[0167] [Figure 20A]FIG. 20A illustrates the mapping and alignment of a patient's image with a treatment coordinate reference frame, according to an embodiment.

[0168] [Figure 20B1] FIG. 20B illustrates a method of treating a patient, according to an embodiment. [Figure 20B2] FIG. 20B illustrates a method of treating a patient, according to an embodiment.

[0169] [Figure 21A] 21A and 21B show screenshots of a 3D segmented image used in accordance with an embodiment system and method.

[0170] [Figure 21B] 21A and 21B show screenshots of a 3D segmented image used in accordance with an embodiment system and method.

[0171] [Figure 21C] 21C-21F show multiple axial images of a target tissue for defining a three-dimensional treatment plan and a user-defined treatment profile within each of the multiple images. [Figure 21D] 21C-21F show multiple axial images of a target tissue for defining a three-dimensional treatment plan and a user-defined treatment profile within each of the multiple images. [Figure 21E] 21C-21F show multiple axial images of a target tissue for defining a three-dimensional treatment plan and a user-defined treatment profile within each of the multiple images. [Figure 21F] 21C-21F show multiple axial images of a target tissue for defining a three-dimensional treatment plan and a user-defined treatment profile within each of the multiple images.

[0172] [Figure 21G] FIG. 21G shows a sagittal view of the target tissue and a plane of the axial images of FIGS. 21C-21F.

[0173] [Figure 21H] FIG. 21H shows a three-dimensional treatment plan based on the multiple images of FIGS. 21A-21F.

[0174] [Figure 21I] FIG. 21I shows a user-entered treatment profile for an image among multiple images.

[0175] [Figure 21J] FIG. 21J illustrates a scan pattern for a fluid flow, according to an embodiment.

[0176] [Figure 21K] FIG. 21K illustrates a bag covering a fluid flow including a water hammer, according to an embodiment.

[0177] [Figure 22A] 22A and 22B show schematic diagrams of a probe being operated according to the principles of an embodiment. [Figure 22B] 22A and 22B show schematic diagrams of a probe being operated according to the principles of an embodiment.

[0178] [Figure 22C] FIG. 22C shows an endoscope positioned within the working channel of the elongate element with the carrier to image tissue as the patient is treated, according to an embodiment.

[0179] [Figure 23A] 23A and 23B show a carrier configured to provide integrated jet delivery, according to an embodiment. [Figure 23B] 23A and 23B show a carrier configured to provide integrated jet delivery, according to an embodiment.

[0180] [Figure 24] FIG. 24 shows a carrier, including a fluid delivery element, and design considerations for a fluid delivery element, according to an embodiment.

[0181] [Figure 25A] 25A-25C illustrate jet deflection, according to an embodiment. [Figure 25B] 25A-25C illustrate jet deflection, according to an embodiment. [Figure 25C] 25A-25C illustrate jet deflection, according to an embodiment.

[0182] [Figure 26A] 26A-26C illustrate jet masking, according to an embodiment. [Figure 26B] 26A-26C illustrate jet masking, according to an embodiment. [Figure 26C] 26A-26C illustrate jet masking, according to an embodiment.

[0183] [Figure 27A] 27A and 27B show variations in jet angle, according to an embodiment. [Figure 27B] 27A and 27B show variations in jet angle, according to an embodiment.

[0184] [Figure 28] FIG. 28 shows multiple jets delivered simultaneously, according to an embodiment.

[0185] [Figure 29] FIG. 29 illustrates a morcellation procedure, according to an embodiment.

[0186] [Figure 30] 30-31B show a single tube design, according to an embodiment. [Figure 31] 30-31B show a single tube design, according to an embodiment.

[0187] [Figure 32] FIG. 32 illustrates a means of registering and locating the treatment system with respect to the human anatomy, according to an embodiment.

[0188] [Figure 33] FIG. 33 illustrates a plurality of expandable structures including a first expandable basket and a second expandable basket, according to an embodiment.

[0189] [Figure 34] FIG. 34 illustrates a means of registering the system with respect to the human anatomy, according to an embodiment.

[0190] [Figure 35] FIG. 35 illustrates a disposable balloon, according to an embodiment.

[0191] [Figure 36] FIG. 36 illustrates tissue ablation and depth control, according to an embodiment.

[0192] [Figure 37] FIG. 37 shows the visible companion area at a first size as shown in FIG.

[0193] [Figure 38] FIG. 38 illustrates tissue ablation depth control, according to an embodiment.

[0194] [Figure 39] FIG. 39 shows an optical image of an entrainment zone flame in saline as shown in FIG. 38 with a different pressure than that shown in FIGS. 36 and 37, according to an embodiment.

[0195] [Figure 40] FIG. 40 illustrates nozzle flow velocity versus maximum penetration depth for multiple pressures and nozzles, according to an embodiment.

[0196] [Figure 41] FIG. 41 illustrates nozzle back pressure versus maximum penetration depth, according to an embodiment.

[0197] [Figure 42]FIG. 42 shows nozzle flow velocity versus back pressure for a 130 micron nozzle and a 150 micron nozzle, according to an embodiment. DETAILED DESCRIPTION OF THE INVENTION

[0198] A better understanding of the features and advantages of the present disclosure will be obtained by reference to the following detailed description that sets forth illustrative embodiments, in which the principles of the presently disclosed embodiments are utilized, and the accompanying drawings of which:

[0199] While the detailed description contains many details, these should not be construed as limiting the scope of the invention, but merely as illustrating different embodiments and aspects of the invention. It should be understood that the scope of the invention includes other embodiments not discussed in detail above. Various other modifications, changes, and variations, which will be apparent to those skilled in the art, may be made in the arrangement, operation, and details of the methods and apparatus of the invention disclosed herein without departing from the spirit and scope of the invention as described herein.

[0200] The embodiments disclosed herein may be combined in one or more of many ways to provide improved treatment to patients. The disclosed embodiments can be combined with prior art methods and devices to provide improved treatment, such as in combination with known methods of prostate surgery and other tissue and organ surgery. It should be understood that any one or more of the structures and steps as described herein can be combined with any one or more additional structures and steps of the methods and devices as described herein, and the figures and supporting text provide an explanation according to the embodiments.

[0201] Although the treatment plans and definitions of treatment profiles and volumes as described herein are presented in the context of prostate surgery, the methods and devices as described herein can be used to treat any tissue of the body and any organ and vessel of the body, including the brain, heart, lungs, intestines, eyes, skin, kidneys, liver, pancreas, stomach, uterus, ovaries, testes, bladder, ears, nose, mouth, bone marrow, adipose tissue, muscle, glandular and mucosal tissue, spinal cord and nerve tissue, soft tissue such as cartilage, hard tissue such as teeth, bone, and body cavities and passageways such as the sinuses, ureters, colon, esophagus, pulmonary passages, blood vessels, and throat.

[0202] Imaging and treatment probes as described herein can be combined in one or more of many ways, and in many embodiments, patient images can be used to define a target volume and target profile of the volume of tissue to be removed. The profile of the tissue to be removed can be planned to effectively remove tissue. Methods and devices for imaging as described herein can be used to beneficially plan for treatment. Alternatively, or in combination, imaging methods and devices as described herein can be used to modify treatment in real time, for example, as the patient is being treated.

[0203] The visible entrainment region can be combined with an image of the tissue and treatment region shown on the display to provide confirmation that the correct amount of tissue will be ablated. In many embodiments, the distance of the visible entrainment region corresponds to a maximum cutting depth so that the surgeon can select the depth of cut based on the image and by adjusting treatment parameters such as one or more of flow rate, nozzle diameter, or pressure.

[0204] As used herein, a visible entrainment region includes a region of cavitation in a fluid stream emitted from an energy source such as a nozzle, and the maximum ablation depth corresponds to the distance of the visible entrainment region. By visible entrainment region, it is meant that a user can visualize the entrainment region using imaging sensitive to the formation of cavitation pockets, such as visual and ultrasound imaging, which scatters waves in response to the cavitation pockets being formed.

[0205] Multiple carrier probes can be provided to allow a user to treat one or more of a number of tissues in a variety of ways. An elongate structural element having a working channel, such as a shaft, remains positioned within the patient when a first carrier probe is exchanged for one or more carrier probes. In many embodiments, the carrier probes can be rapidly exchanged while the linkage remains fixedly attached to the elongate element anchored to the patient's internal structure. Each of the carrier probes inserted into the patient can be identified, for example, based on a treatment plan.

[0206] As used herein, a processor encompasses one or more processors, e.g., a single processor, or multiple processors, e.g., in a distributed processing system. A controller or processor as described herein generally includes a tangible medium to store instructions that implement the steps of a process, and a processor may comprise, for example, one or more of a central processing unit, programmable array logic, gate array logic, or field programmable gate array.

[0207] As used herein, a transverse plane of an image may also be referred to as a horizontal plane of an image, an axial plane of an image, or a transverse tomographic plane of an image. An image along an axial plane may also be referred to as an axial image.

[0208] As used herein, a probe includes an object that is inserted into a subject, such as a patient.

[0209] As used herein, like characters distinguish between like elements.

[0210] As used herein, a real-time image shown on a display includes an image shown within a few seconds of the event shown. For example, real-time imaging of a tissue structure includes providing a real-time image on a display within about 10 seconds of the image being acquired.

[0211] As used herein, the terms distal and proximal refer to locations referenced from the device, which may be as opposed to anatomical references. For example, a distal location on the probe may correspond to a proximal location on the patient's elongate member, and vice versa.

[0212] Automated robotic control, in which the movement of the water jet is motorized and under computer control with preselected routines, enables precise and finely detailed ablation not possible with manual control. Benefits include a reduction in the time required for the procedure, fewer complications, improved outcomes, and less training time required for the surgeon. Many of these improvements result from reducing or eliminating the need for manual dexterity on the part of the treating physician. Automatic control also allows the nozzle cutting force to be increased to levels not achievable with fully manual control. The system may also be manually controlled during less critical portions of the procedure, such as during the initial selection of the area to be operated on and corrected during cutting and cauterization. Even during these less critical stages of the protocol, the increased precision and smoothness provided by automatic control can provide reduction and filtering of hand tremors. Another significant advantage is that automation allows for preliminary testing or "dry runs" of the procedure. When a cutting routine is selected, the limits of the area can be selected using a joystick or other control element to position the laser during a simulated non-cutting procedure. Changes can be made before cutting begins so that errors can be corrected before the actual procedure begins.

[0213] Closed-loop and real-time automation are new capabilities offered by robotic automation, including intraorgan ablation volume registration and in-situ depth and volume measurement. The ability to input organ geometry data into the control system, for example, from ultrasound or other preoperative or real-time images, allows for precise registration of the ablation area within the organ. This eliminates the imprecision of manual techniques with respect to critical tolerances, such as how close the ablation is to the surface of the capsule and / or the neurovascular bundle within the prostate. Additionally, the shape of the ablated volume itself may be selectable and adjustable from a set of preprogrammed routines, with the details of how to control the cutting motion and pressure pre-solved through extensive engineering knowledge stored in the robotic surgical tool, ready for access by the surgeon at the push of a button. For example, the ablated shape of the tissue may comprise a predetermined treatment profile, such as one or more of a dome shape, a cube shape, a teardrop shape, or directly from a 3D rendering of the target volume, as described herein and illustrated below, for example, in the two screenshots of FIGS. 21A and 21B. Additionally, the surgeon can adjust cutting parameters in real time based on feedback provided by the ultrasound image, adding another layer of safety to the system.

[0214] Incorporation by Reference

[0215] The subject matter of Figures 1 through 11 and corresponding text is incorporated herein by reference in its entirety, and is incorporated herein by reference in its entirety, in accordance with U.S. Patent Application Serial No. 12 / 700,568, filed February 4, 2010, entitled "MULTI FLUID TISSUE RESECTION METHODS AND DEVICES," which was published as U.S. Patent Application Publication No. 20110184391 [Attorney Docket No. 41502-703.501], and in accordance with U.S. Patent Application Serial No. 20110184391 [Attorney Docket No. 41502-703.501], the entire disclosures of which have been previously incorporated herein by reference.

[0010] As described in PCT Application No. PCT / US2011 / 023781, filed April 8, 2007, entitled "FLUID TISSUE RESECTION METHODS AND DEVICES," published November 8, 2011 as WO2011097505, which is incorporated by reference.

[0216] Referring to FIG. 1 , an exemplary prostate tissue debulking device 10 constructed in accordance with the principles of the present invention generally comprises a catheter assembly including a shaft 12 having a distal end 14 and a proximal end 16. The shaft 12 will typically be a polymer extrusion including one, two, three, four, or more axial lumens extending from a hub 18 at the proximal end 16 to a location near the distal end 14. The shaft 12 will generally have a length in the range of 15 cm to 25 cm and a diameter in the range of 1 mm to 10 mm, usually 2 mm to 6 mm. The shaft will have sufficient column strength so that it can be introduced upward through the male urethra, as described in more detail below.

[0217] The shaft includes an energy source positioned in the energy delivery region 20, where the energy source can be any one of several specific components, as discussed in further detail below. Distal to the energy delivery region, an inflatable anchoring balloon 24 will be positioned at or very near the distal end 14 of the shaft. The balloon will be connected through one of the axial lumens to a balloon inflation source 26 connected through the hub 18. In addition to the energy source 22 and the balloon inflation source 26, the hub will further optionally include connections for an infusion / irrigation source 28, a suction (vacuum) source 30, and / or an insufflation (pressurized CO or other gas) source 32. In an exemplary embodiment, the infusion or irrigation source 28 can be connected through an axial lumen (not shown) to one or more delivery ports 34 proximal to the balloon anchor 24 and distal to the energy delivery region 20. The suction source 30 can be connected to a second port or opening 36, typically located proximal to the energy delivery region 20, while the insufflation source 32 can be connected to an additional port 38, also typically located proximal to the energy delivery region. The location of the ports 34, 36, and 38 is not critical, but it will be understood that certain locations may provide certain advantages as described herein, and that lumens and delivery means can be provided by additional catheters, tubes, and the like, including, for example, coaxial sleeves, sheaths, and the like, that can be positioned over the shaft 12.

[0218] While the present embodiments are described with reference to the human prostate, it will be understood that they may be used to treat mammalian prostates generally. Referring now to Figures 2A-2D, the prostate tissue debulking device 10 is introduced through the urethra U to a region within the prostate gland P located immediately distal to the bladder B. The anatomy is shown in Figure 2A. Once the catheter 10 is positioned so that the anchoring balloon 24 is located just distal to the bladder neck BN (Figure 2B), the balloon can be inflated to preferably occupy substantially the entire interior of the bladder, as shown in Figure 2C. Once the anchoring balloon 24 is inflated, the position of the prostate tissue debulking device 10 will be fixed and stabilized within the urethra U so that the energy delivery region 20 is positioned within the prostate gland P. It will be understood that proper positioning of the energy delivery region 20 depends solely on the inflation of the anchoring balloon 24 within the bladder. When the prostate gland is located directly proximal to the bladder neck (BN), the delivery area can be properly localized by spacing the distal end of the energy delivery area very close to the proximal end of the balloon, typically within a range of 0 to 5 mm, preferably 1 to 3 mm. After the anchoring balloon 24 is inflated, energy can be delivered into the prostate gland for debulking, as shown by the arrows in FIG. 2. Once energy has been delivered over the desired surface area for a period of time, the energy area can be stopped, and the prostate gland will be debulked to relieve pressure on the urethra, as shown in FIG. 2D. At that time, irrigation fluid may be delivered through port 34 and aspirated into port 36, as shown in FIG. 2D. Optionally, after treatment, the area can be ablated using an ablation balloon and / or stent, which can be deployed using a modified or separate catheter device.

[0219] 3-7, several exemplary energy delivery regions are described. Referring now to FIG. 3, a first exemplary prostate ablation device 110 constructed in accordance with the principles of the present invention includes a shaft 112 having a proximal end 114 and a distal end 116. A plurality of nozzles 118 are mounted on the shaft 112 at a location spaced proximally from the distal end 116 by a distance ranging from 1 cm to 5 cm. The nozzles, typically ceramic cores capable of generating plasma or ports capable of directing a radially outward flow of a conductive fluid, may be mounted on a structure 120 that allows the nozzles 118 to be moved radially outward, as shown by the dashed lines in FIG. 3. An anchor 122, shown as an inflatable balloon, is mounted on the distal end 116 of the shaft 112 at a location between the nozzles 118 and a distal tip 124. The expandable structure 122 may be expandable within the bladder to anchor the shaft 112 so that the nozzle array 118 is located within the prostate, as described in further detail below. The shaft 112 will include lumens, passageways, conductive wires, and the like for delivering energy and substances from the proximal end 114 to the distal end 116 of the shaft. For example, an RF energy source 126 will typically be connected to the shaft 112, usually the nozzle 118, for delivering RF energy through a lumen within the shaft 112 to a conductive fluid delivered from the source 128 to the nozzle 118. Another lumen, channel, or conduit will typically be provided to allow suction to a vacuum source 130 connected to one or more suction ports 132. Another conduit may be provided within the shaft 112 to allow the introduction of an irrigation fluid, such as saline, from a source 134 to a port 136. In other cases, it will be possible to connect the suction and irrigation sources 130 and 134 to a common port so that suction and irrigation can occur sequentially rather than simultaneously. Additionally, optionally, an internal lumen, conduit, or the like may be provided to connect an insufflation source 140 to one or more insufflation ports 142 on the shaft in the region of the array 118. Finally, an internal lumen, conduit, or the like may be provided to connect the balloon 122 to a balloon inflation source 144.

[0220] 4, an exemplary energy delivery region 20 may be formed by a high-pressure nozzle 200 carried on a delivery tube 380 disposed within the shaft 12. The carrier tube 380 may be translated axially, as indicated by arrow 204, and / or rotated, as indicated by arrow 206, so as to scan or raster a fluid stream 208 emanating from the nozzle 200 over all or a selected portion of the urethra within the prostate. Specific pressures and other details for such high-pressure water treatments are described, for example, in Jian and Jiajun (see above).

[0221] 5, the energy source within the energy delivery region 20 may comprise an optical fiber waveguide or fiber bundle 220 carried on a rotating and translating shaft 380. The optical waveguide 220 delivers laser or other coherent light energy in a beam 222 that can be scanned or rastered over the urethral wall and prostate tissue by rotating and / or translating the carrier tube 380.

[0222] 6, laser energy from an optical waveguide or fiber bundle 230 may be directed axially to a mirror 232, with both the waveguide and mirror carried on a rotating and axially translating carrier tube 380. Again, by rotating and / or translating the carrier tube 380, the emanating beam 234 can be scanned or rastered over the urethral wall.

[0223] 7, in yet another embodiment, the rotation and axial translation tube 380 may carry an electrode 240 that protrudes laterally from the tube. The electrode 240 may be adapted for connection to a radiofrequency energy source so that radiofrequency energy can be delivered in either monopolar or bipolar mode when the electrode contacts the urethral wall and prostate tissue. Thus, the radiofrequency energy can ablate tissue overlying selected volumes and regions of prostate tissue. Optionally, by varying the nature of the radiofrequency energy, the electrode 240 can also be used to cauterize tissue after it has been treated.

[0224] In one embodiment of the present invention, the device is configured to selectively ablate tissue, causing the removal of some tissue components while leaving other tissue components intact. For example, the prostate gland and adjacent regions contain a variety of tissue components, including prostatic tissue, intraprostatic blood vessels, fibromuscular stroma, capsular tissue, sphincter muscle, seminal vesicles, etc. When treating BPH or other prostate conditions, it is desirable to remove prostatic tissue and leave other tissues, such as blood vessels and capsular tissue, substantially undamaged.

[0225] As referred to herein, the term ablation is intended to include any removal of tissue, including removal of one or more clumps of tissue cells, removal of some tissue cells, and the like.

[0226] One advantage of treating BPH with selective tissue ablation is the reduced (or no) need for ablation, since there is little or no damage to intraprostatic blood vessels, resulting in limited bleeding. Another advantage is the reduced likelihood of incontinence or impotence, since selective ablation reduces the risk of perforating or otherwise damaging surrounding tissues, such as the prostatic capsule, sphincter, and seminal vesicles.

[0227] When using a fluid stream to ablate tissue, selective tissue ablation may be achieved by varying one or more parameters of the fluid stream, such as the pressure within the nozzle or other fluid delivery element, or the flow rate of the fluid during flow, to remove some tissue compositions while leaving other tissue compositions substantially undamaged.

[0228] In one embodiment, the fluid flow parameters may be configured to leave non-target tissue undamaged even when these tissues are exposed to the fluid flow for an extended period of time, i.e., a period that is typically sufficient to achieve the desired ablation. In another embodiment, the fluid flow parameters may be configured to ablate the target tissue at a substantially higher rate than the non-target tissue, thereby limiting damage to the non-target tissue. Such parameters may be adjusted depending on the target tissue to be selectively ablated.

[0229] In one embodiment, the rate of ablation is configured to be higher for glandular tissue than for non-glandular tissue. The rate of ablation may be configured by varying the fluid pressure or by adjusting other fluid parameters, as described above. Specifically, the rate of ablation for glandular tissue may be configured to be significantly higher than for non-glandular tissue, so that the non-glandular tissue remains effectively undamaged during the treatment period. For example, the rate of ablation for glandular tissue may be configured to be at least two times higher than for non-glandular tissue. As another example, the rate of ablation for glandular tissue may be configured to be at least ten times higher than for non-glandular tissue.

[0230] It is noted that tissue ablation has a critical pressure (pressure below which the tissue will not ablate and above which the tissue can be removed) because the removal process involves tearing the tissue, stretching the tissue on a microscale to the point where the tissue matrix ruptures or ruptures. Because tissue is elastic, there will be a critical failure point. Different types of tissue will have different critical failure points and therefore different critical pressures associated with them.

[0231] In fact, considering a specific fluid delivery element size (such as nozzle diameter, etc.), each tissue type typically has a critical pressure of the fluid source (hereinafter also referred to as Pcrit) below which the resection rate approaches zero and above which the resection rate generally increases monotonically, perhaps exponentially. Specifically, due to differences in tissue composition, the pressure of the fluid source may be configured to selectively excise a particular type of tissue while generally leaving other tissue types with higher critical pressures undamaged.

[0232] An important aspect of excising tissue in a multi-tissue environment according to this embodiment is that it is possible to surgically perform a treatment plan in which one tissue type is excised and another tissue type remains substantially undamaged. This occurs most prominently when operating at a pressure between the critical pressures of the two tissue types. As seen in FIG. 8, the operating pressure p0 of the fluid flow is configured to be greater than the critical pressure of tissue 1 ( / >,,>pcriti) so that tissue 1 receives a resection rate greater than zero, while maintaining a pressure p0 (p0 < pcrit2) below the critical pressure of tissue 2 so that tissue 2 receives a resection rate that is substantially near zero. In such a configuration, it can be said that the fluid flow is configured to selectively excise tissue 1 rather than tissue 2.

[0233] In one embodiment configured to treat BPH, the fluid source pressure is configured to be above the critical pressure of the prostate tissue but below the critical pressure of the non-prostate tissue. In such an embodiment, the pressure is high enough to excise the glandular tissue but too low to substantially excise or damage non-glandular tissues such as the blood vessels within the prostate, fibromuscular stroma, and capsular tissue. In one embodiment, the fluid is pressurized to a pressure within the range of about 1 to 30,000 psi, more preferably within the range of about 50 to 1,500 psi, and most preferably within the range of about 100 to 1,000 psi before exiting the fluid delivery element.

Example

[0234] The following examples illustrate some tissue critical pressures for fluid flow ablation. Note that the following configurations are provided as examples and should not be construed as limiting.

[0235] Example 1: Exemplary Critical Pressures of Different Kidney Tissue Compositions. Tissue critical pressures were measured in porcine kidneys. Kidney tissue was chosen because its composition is similar to that of prostate tissue. A columnar fluid stream approximately 200 microns in diameter was used for tissue ablation. Glandular tissue (the pink outer portion of the kidney) is very soft and easily tears with finger pressure, while the interior of the kidney contains tougher vascular tissue. The critical pressure for glandular tissue using this fluid stream was found to be approximately 80 psi and for vascular tissue approximately 500 psi, as seen in Table 1 below.

[0236] [Table 1]

[0237] For example, experiments have shown that when ablating a porcine kidney using a nozzle approximately 200 microns in diameter with a fluid source pressure of approximately 500 psi, the rate of ablation over a 10 cm area is approximately 1 cm per 30 seconds for glandular tissue (i.e., 10 cc ablation per 30 seconds) and less than approximately 0.1 cm per 180 seconds for vascular tissue, representing approximately a 60-fold difference in ablation rate. Thus, more glandular tissue than vascular tissue will be ablated within the same ablation period. The ablation period can thereby be configured to allow ablation of glandular tissue without substantial damage to vascular tissue. The rate of ablation may be adjusted by varying the fluid source pressure and / or the nozzle size. For example, the rate of ablation of glandular tissue may be adjusted to approximately 1 cc / min, 5 cc / min, 10 cc / min, 30 cc / min, or other rates. As discussed above, it is understood herein that varying the nozzle size may necessitate varying the fluid source pressure to cause the fluid stream to act on the tissue with sufficient force to achieve the desired ablation rate.

[0238] 9a is a flow chart illustrating a method for selective prostate ablation, according to one embodiment. In step 700, the device is positioned and anchored within the urethra as described above. In step 701, various fluid parameters, such as the pressure of the fluid source and the shape of the fluid stream, are configured to ablate a specific tissue type, such as prostate tissue. By configuring the fluid parameters, the fluid force, the rate of ablation, the treatment time, the area of ​​tissue ablated, etc., can be controlled to achieve controlled selective ablation. After the parameters are configured, in step 702, the device is configured to emit a fluid stream to ablate the target tissue. If, in step 703, it is determined that treatment is complete, the device is withdrawn from the urethra U in step 704.

[0239] However, if it is determined in step 703 that the treatment is not yet complete, the fluid parameters may be reconfigured as necessary, as described in step 701, and the cycle of steps repeats until the treatment is complete. In particular, reconfiguration of the fluid parameters is advantageous in embodiments where it is desired to ablate two different types of tissue for a complete treatment. In such embodiments, the fluid parameters may be adjusted to account for changes in the type of target tissue being ablated.

[0240] Typically, after some or all of the glandular tissue has been ablated, other tissue types, such as vascular or capsular tissue, will be exposed to the fluid flow. While the fluid flow parameters are configured to selectively ablate glandular tissue, it is also contemplated that the fluid parameters may be dynamically adjusted during the ablation procedure to account for the gradual exposure of non-glandular tissue and to fine-tune the ablation selectivity as needed. In this manner, after the fluid parameters are reconfigured in step 701, the reconfigured fluid flow is then released in step 702 to continue tissue ablation, and operation continues until treatment is complete.

[0241] In particular, it is noted that when treating the prostate from within the urethra, the urethral wall is interposed between the fluid flow source (such as a nozzle or other fluid delivery element) and the target prostate tissue to be ablated.

[0242] Thus, in one embodiment, the fluid flow parameters are configured to initially ablate and penetrate a portion of the urethral tissue (e.g., the urethral wall). However, because the composition of prostate tissue is weaker than that of urethral tissue, it is desirable to avoid ablating glandular tissue with the same fluid flow force as that used to ablate the urethral wall. To achieve this, the fluid flow may be used for a period sufficient to ablate and penetrate the urethral wall, rather than for a longer period. Thus, a reduced intensity fluid flow may be used to ablate the prostate tissue.

[0243] 9b is a flow chart illustrating a method for selective prostate ablation in which the fluid stream is configured to first penetrate and ablate the urethral wall, according to one embodiment. In step 801, the device is positioned and anchored within the urethra as described above. In step 802, the device is configured to emit a fluid stream of sufficient force to ablate and penetrate the urethral wall. In step 803, after the fluid stream has penetrated the urethral wall, the fluid stream is adjusted to a level that selectively ablates desired prostate tissue while leaving intraprostatic blood vessels, capsule, and other non-glandular tissue substantially undamaged.

[0244] Additionally, it is contemplated that the shape of the fluid stream also affects selective ablation. While the fluid stream is illustratively shown in FIG. 10 a as a columnar fluid stream 333 or a diverging fluid stream 334, it is contemplated that the fluid stream may be of any shape or configuration that enables ablation in accordance with embodiments of the present invention. Specifically, there are numerous advantages to both columnar and diverging fluid stream configurations, as described in further detail below.

[0245] In the columnar fluid stream configuration 333, the device emits the fluid stream as a substantially focused, rod-like fluid stream with a substantially zero divergence angle. In one embodiment, the columnar fluid stream is configured as a generally straight or non-diverging fluid stream. In such a configuration, the device emits the fluid stream as a substantially cylindrical or other non-diverging shape, thereby delivering energy to tissue over an area or spot size that is largely independent of the tissue distance from the fluid delivery element. Optionally, the fluid stream may be adjusted to converge to focus the energy delivered to tissue, for example, if the fluid delivery element includes multiple nozzles or if the fluid contains gas bubbles.

[0246] 10b shows a cross-sectional view of a device for emitting a columnar fluid stream to modify tissue, such as the prostate. An elongated element 310 of the device (such as a shaft as described above) is positioned within the urethra U. A fluid delivery element 320, disposed on a carrier tube (not shown) within the elongated element 310, is configured to emit a columnar fluid stream 333. As understood herein, the fluid delivery element 320 may comprise a nozzle, as described above, or any other element configured to emit a fluid. The columnar fluid stream 333 is configured to ablate tissue, such as the urethral wall UW and prostate tissue P, within the ablation region RA.

[0247] Because the width of the ablation region RA is substantially independent of fluid distance from the fluid delivery element 320, one characteristic of the columnar fluid flow configuration is that the ablation region RA remains substantially constant for a distance from the fluid delivery element 320. This is advantageous because the ablation region RA remains focused and constant as the fluid flow 333 travels away from the fluid delivery element 320, thereby transferring energy to tissue in the focused region. The concentration of energy within the focused ablation region RA is particularly advantageous when ablating or penetrating tough tissue, such as the urethral wall UW. In one embodiment, the columnar nature of the fluid flow may be varied by introducing pressure fluctuations in the fluid delivery. For example, the columnar nature of the fluid flow may be varied by mechanically and controllably introducing a generally solid object into the fluid delivery path, such as after the opening in the fluid delivery element 320 or in the path of the fluid flow after exiting the opening in the fluid delivery element 320. In another example, the columnarity of the fluid flow may be altered by introducing a vibrating element, such as a piezoelectric element or the like, into the fluid path to create pressure fluctuations.

[0248] In another embodiment, the fluid stream is configured as a diverging fluid stream 334, as seen in Figure 10a. A diverging fluid stream 334 is one in which the fluid exits a fluid stream source, such as fluid delivery element 320, and diverges in a substantially conical shape, with the tip of the cone at the fluid stream source. The rate of ablation of the diverging fluid stream 334 can be expressed as a function of the distance z from the fluid delivery element 320 emitting the fluid to the tissue being ablated. As shown in Figure 10a, z is farther from the orifice than z / ; therefore, the rate of ablation at z / is higher than the rate of ablation at z^.

[0249] The diverging fluid stream 334 may be characterized by a divergence angle of the fluid stream. In one embodiment, the divergence angle is configured to be between about 0 and 90 degrees, more preferably between about 2 and 45 degrees, more preferably between about 4 and 20 degrees, and most preferably about 7 degrees, although it is contemplated that the divergence angle may be varied as desired.

[0250] Additionally, the diverging fluid stream 334 may be characterized by the cross-sectional shape of the fluid stream. Generally, the diverging fluid stream 334 has a cross-sectional area, or spot size, that increases with greater distance from the fluid stream source (e.g., fluid delivery element 320), thereby proportionally reducing the force of the fluid stream per unit area. This increase in spot size generally results in faster ablation rates of tissue closer to the fluid stream source.

[0251] In one embodiment, the cross-sectional shape of the diverging fluid flow 334 is configured as a generally narrow rectangle (for a fan-shaped fluid flow). In another embodiment, the cross-sectional shape of the diverging fluid flow 334 is configured as a generally circle (for a cone-shaped fluid flow), with the smallest cross-sectional area at the source of the fluid flow. Note that the cross-sectional shape of the diverging fluid flow 334 may be configured as any shape (e.g., elliptical, or irregular) that encloses a non-zero area.

[0252] 10c shows a cross-sectional view of a device that emits diverging fluid streams to modify tissue, such as the prostate. An elongated element 310 of the device is positioned within the urethra U. A fluid delivery element 320, disposed on a carrier tube (not shown) within the elongated element 310, is configured to emit a diverging fluid stream 334. The diverging fluid stream 334 is configured to ablate tissue, such as the urethral wall UW and prostate tissue P, within an ablation area RA. The ablation area RA covered by the diverging fluid stream 334 increases as the fluid stream moves away from the fluid delivery element 320, thereby proportionally reducing the intensity of the fluid stream per unit area.

[0253] A characteristic of the diverging fluid stream 334 is that the ablation width increases as a function of distance from the fluid delivery element 320, while the rate of ablation per unit area decreases as a function of distance from the fluid delivery element 320. This is because the total energy delivered in the fluid stream is generally constant (not accounting for any decrease in fluid velocity), and yet the energy is delivered over a larger area. Thus, the energy delivered per area decreases, which is the primary parameter on which the rate of ablation depends. Thus, the rate of ablation per unit area decreases as a function of distance.

[0254] Furthermore, with a diverging fluid stream 334, the volumetric ablation rate can be generally constant as a function of distance. That is, while the rate of ablation per unit area decreases, the total area ablated increases proportionally, and therefore the total ablation volume remains generally constant. Note that if the areal ablation rate as a function of areal energy density were nonlinear and monotonically increasing with energy, the volumetric ablation rate would decrease as a function of distance from the fluid delivery element 320. Furthermore, note that any deceleration of the fluid stream particles (e.g., droplets) would also decrease the volumetric ablation rate as a function of distance.

[0255] 11 , the device includes an elongate element 310, such as a shaft, configured to be inserted into a body region. The elongate element 310 includes a window that exposes a carrier tube 380 and other components described below. The window reveals the carrier tube 380 and a high-pressure fluid delivery element 320 disposed on the carrier tube 380. The fluid delivery element 320 is connected to a fluid source (not shown) via a fluid lumen 390 that delivers fluid from the fluid source to the fluid delivery element 320.

[0256] Optionally, elongate element 310 may be covered by a sheath or other covering (not shown) when it is introduced through the urethra. When fully covered by the sheath, the window is protected to reduce abrasion and damage to the urethra as elongate element 310 is advanced. Once in place, the sheath is retracted, exposing the window. Carrier tube 380 may then be rotated and advanced and / or retracted so that fluid is delivered through fluid delivery element 320.

[0257] Additionally and optionally, the device may include a shielding element (not shown) positioned to substantially cover the fluid delivery element 320 while maintaining a space between the fluid delivery element 320 and the shielding element. This, in turn, effectively maintains a space between the fluid delivery element 320 and any tissue that may affect the shielding element. In one embodiment, the shielding element is a substantially flat, sheet-like element positioned over the fluid delivery element 320. The shielding element is positioned or shaped to allow the carrier tube 380 to move within the elongate element 310 as needed. For example, the shielding element may be curved to follow the curvature of the carrier tube 380. The shielding element includes openings to allow the fluid flow emitted by the fluid delivery element 320 to proceed unobstructed through the openings and affect the tissue. The openings may be circular or may comprise other shapes. One advantage of such a shielding element is that it protects the fluid delivery element 320 from being damaged during insertion and removal procedures and / or during treatment. Another advantage of the shielding element is that during or after fluid ejection, fluid returning toward the fluid delivery element 320 may travel through the shielding element openings (or through other paths around the shielding element) into the space between the shielding element and the fluid delivery element 320. Such returning fluid may then be directed out of that space so that fluid ejection is not blocked or impeded by such returning fluid.

[0258] The shielding element may further be configured such that the space between the shielding element and the fluid delivery element 320 is in continuous communication with the waste disposal lumen via a low-flow resistance fluid pathway. This creates a low-flow resistance pathway between the fluid delivery element 320 and an external destination for such waste, such that waste and fluid exiting the fluid delivery element 320 can easily exit the area surrounding the fluid delivery element 320. Low resistance in this case is understood to mean a lower flow resistance compared to the flow resistance of the fluid delivery element 320. This configuration advantageously prevents backpressure in the fluid delivery element 320, which would otherwise reduce flow, thereby allowing the fluid flow emitted by the fluid delivery element 320 to proceed substantially undisturbed by waste and return fluid.

[0259] Fluid delivery element 320 may be a single nozzle, multiple nozzles, or an array of nozzles in various configurations. Fluid delivery element 320 is configured to emit fluid radially outward as fluid stream 331 with sufficient force such that upon contact with tissue, fluid stream 331 ablates tissue. Fluid stream 331 may be perpendicular to elongate element 310 or may be configured to be at various angles relative to elongate element 310.

[0260] Carrier tube 380 may be axially translated, rotated, oscillated, or rotationally oscillated relative to elongate element 310 so as to cause fluid stream 331 to scan or raster to ablate a desired area or volume of tissue. The desired area or volume may be spherical, cylindrical, or any other predetermined area or volume of arbitrary shape and dimensions.

[0261] Additionally, and optionally, when the device is not being used to ablate tissue, the carrier tube 380 may be positioned such that the fluid delivery element 320 and / or any other elements (such as visualization or ablation elements) are positioned away from the window, thereby reducing the risk of damage to such elements and reducing any risk of unintended ablation of tissue.

[0262] The device further includes at least one insufflation port 340 disposed on elongate element 310. Insufflation port 340 is connected via one or more lumens to an insufflation source (not shown), which delivers fluid 330 through insufflation port 340 into the body region to expand surrounding tissue and create a working space. The device further includes at least one removal port 360 for removal of debris products, such as ablation products, ablation fluids, other waste products, or mixtures thereof. Elongate element 310 may include lumens, passageways, conductive wires, and the like configured to deliver energy and / or substances from the proximal end to the distal end of elongate element 310 and / or to remove debris and waste products, the details of which are described above.

[0263] Optionally, in addition to the fluid delivery element 320, the device may include an electromagnetic energy delivery port 350 disposed on the carrier tube 380 and positioned near or within the fluid delivery element 320. Electromagnetic energy 332 is delivered to the energy delivery port 350 using one or more conduits 351, such as optical fibers or other waveguides within the carrier tube 380 and elongate element 310, also as described in further detail above. The electromagnetic energy 332 may be radio frequency energy, coherent or non-coherent light, or any other modality of electromagnetic energy. The energy delivery port 350 is configured to deliver the energy 332 through the interior of the fluid stream 331 such that the electromagnetic energy 332 may ablate tissue instead of, or in combination with, fluid ablation.

[0264] Additionally, and optionally, the various electromagnetic energy modalities described above may be configured to ablate tissue in combination with, or independent of, tissue ablation. Because selective tissue ablation as disclosed herein generally causes little or no damage to remaining tissue, such as vascular tissue, and therefore causes limited or no bleeding, such ablation need only be used on a limited basis, if at all. It is contemplated that when electromagnetic energy is delivered to tissue by fluid flow 331 for ablation, the fluid source pressure may be adjusted to generally be below the critical pressure for tissue ablation so that no additional tissue is ablated.

[0265] Alternatively, or in addition, ablation may be achieved using other means, for example, using an ablation balloon and / or stent placed in contact with the tissue using a catheter device, as described above.

[0266] Additionally, the device may include an optional deflecting element, e.g., positioned within or within elongate element 310, away from the window, configured to deflect fluid emitted by fluid delivery element 320 back toward fluid delivery element 320, thereby removing any debris that may accumulate on fluid delivery element 320 and / or energy delivery port 350 during tissue ablation. Additionally, fluid delivery element 320 in combination with the deflecting element may be configured to clean a portion or substantially all of fluid delivery element 320, any visualization or ablation element, and / or carrier tube 380. The deflecting element may be configured to be substantially flat or concave. Alternatively, the deflecting element may be configured as any shape or design.

[0267] Additionally, the deflecting element may be configured as a protective element for the fluid delivery element, which may be positioned at a specific location relative to the protective element that protects the prostate gland from unexpected fluid release and protects the fluid delivery element 320 from clogging or blockage by tissue, for example, during insertion and removal from the body.

[0268] Carrier tube 380 includes a carrier. The carrier may optionally comprise a tubular structure. While referring to carrier tube 380 according to an embodiment, the carrier may comprise a substantially non-tubular cross-section, e.g., a rectangular cross-section, extending along a longitudinal portion of the carrier as described herein. Thus, while a carrier tube is shown and described in the drawings, it should be understood that the carrier may comprise a non-circular carrier in each of the drawings and supporting text as described herein.

[0269] FIG. 12 shows components of a treatment probe 350, according to an embodiment. A carrier tube 380 includes a concentric arrangement of a first fluid delivery port and a second fluid delivery port. The fluid delivery element 320 emits a fluid stream 331. The fluid stream 331 defines an axis extending outward from the fluid delivery element 320. The fluid stream 331 may comprise a diverging stream 334 or a columnar stream 333, as described herein. The fluid delivery element 320 includes a nozzle 322. The nozzle 322 may have a substantially circular cross-section. The nozzle 322 may include an internal channel having a circular cross-section, where the internal channel extends cylindrically. The internal channel extends along an axis corresponding to the axis of the fluid stream 331.

[0270] A port 340 is concentrically disposed around the fluid delivery element 320. The port 340 includes a substantially annular channel extending circumferentially around the fluid delivery element 320 and the nozzle 322. The port 340 may comprise an insufflation port as described herein. The port 340 emits the fluid 330 in a substantially concentric arrangement with the fluid stream 331. The substantially concentric arrangement has the advantage of providing a protective jacket around the fluid stream 331 with the first fluid 330 extending outward from the port 340 to beneficially direct the therapeutic flow toward the tissue. An energy conduit 351 extends from an energy source, such as a laser, toward the fluid delivery element 320. The energy conduit may comprise, for example, an optical fiber or multiple optical fibers coupled to the laser. The optical fiber may extend toward the nozzle 322 and be concentrically aligned with an axis defined by the nozzle 322 to provide efficient energy transfer of light energy emitted from the optical fiber through the nozzle 322. Structures can be provided near the distal end of the optical fiber to align the optical fiber with the channel of the nozzle 322. The concentric arrangement of the optical fiber, nozzle, and port 340 can provide patient therapy, allowing for patient visualization and treatment. Fluid emissions from the port 340 can include liquids, such as saline, or gases, such as CO2. The fluid delivered through the port 340 can be user-selectable using an interface, as described herein.

[0271] The fluid flow 331 can provide an optical waveguide directed toward the tissue. In many embodiments, the fluid flow 331 includes a refractive index greater than that of the fluid emitted through the port 340. The waveguide medium can be a liquid or a gas, and the envelope medium emitted from the port 340 can be a liquid or a gas. An intermediate medium can be located between the probe and the target tissue. The intermediate medium can be one or more of a liquid or a gas, for example, saline, air, or carbon dioxide. In many embodiments, the intermediate medium includes a fluid emitted from the nozzle 322 and a fluid emitted from the annular port 340.

[0272] 13A and 13B show a system for treating a patient, according to an embodiment. System 400 includes a treatment probe 450 and may optionally include an imaging probe 460. Treatment probe 450 is coupled to a console 420 and a linkage 430. Imaging probe 460 is coupled to an imaging console 490. Patient treatment probe 450 and imaging probe 460 can be coupled to a common base 440. The patient is supported using a patient support 449. Treatment probe 450 is coupled to base 440 using an arm 442. Imaging probe 460 is coupled to base 440 using an arm 444.

[0273] The patient is positioned on a patient support 449 so that the treatment probe 450 and the ultrasound probe 460 can be inserted into the patient. The patient can be positioned in one or more of a number of positions, such as prone, supine, upright, or inclined. In many embodiments, the patient is positioned in a lithotomy position, for example, stirrups may be used. In many embodiments, the treatment probe 450 is inserted into the patient in a first direction on a first side of the patient, and the imaging probe is inserted into the patient in a second direction on a second side of the patient. For example, the treatment probe can be inserted into the patient's urethra from the front of the patient, and the imaging probe can be inserted transrectally into the patient's intestine from the back of the patient. The treatment probe and imaging probe can be positioned within the patient with one or more of urethral tissue, urethral wall tissue, prostate tissue, intestinal tissue, or intestinal wall tissue extending therebetween.

[0274] The treatment probe 450 and the imaging probe 460 can be inserted into a patient in one or more of many ways. During insertion, each arm may have a substantially unlocked configuration to allow the probe to be rotated and translated as desired to insert the probe into the patient. When the probe is inserted into a desired location, the arms can be locked. In the locked configuration, the probes can be oriented with respect to each other in one or more of many ways, such as parallel, skewed, horizontal, oblique, or non-parallel. It can be useful to determine the orientation of the probe using an angle sensor as described herein to map imaging probe image data to a treatment probe coordinate reference. Mapping tissue image data to a treatment probe coordinate reference space can enable precise targeting and treatment of tissue identified for treatment by an operator, such as a physician.

[0275] In many embodiments, the treatment probe 450 is coupled to the imaging probe 460 to align the treatment with the probe 450 based on images from the imaging probe 460. Coupling can be achieved using a common base 440 as shown. Alternatively, or in combination, the treatment probe and / or the imaging probe may include magnets to hold the probe in alignment through the patient's tissue. In many embodiments, the arm 442 is a movable and lockable arm so that the treatment probe 450 can be positioned at a desired location within the patient. When the probe 450 is positioned at a desired location in the patient, the arm 442 can be locked using an arm lock 427. The imaging probe can be coupled to the base 440 using the arm 444, which can be used to adjust the alignment of the probe when the treatment probe is locked in place. The arm 444 may include a lockable and movable probe, for example, under the control of the imaging system, or a console and user interface. The movable arm 444 may be finely actuated so that the imaging probe 440 can be adjusted relative to the treatment probe 450 with movements as small as one millimeter, for example.

[0276] In many embodiments, the treatment probe 450 and the imaging probe 460 are coupled to angle sensors so that treatment can be controlled based on the alignment of the imaging probe 460 and the treatment probe 450. An angle sensor 495 is coupled to the imaging probe 450 using the support port 438. An angle sensor 497 is coupled to the imaging probe 460. The angle sensor may comprise one or more of many types of angle sensors. For example, the angle sensor may comprise a goniometer, an accelerometer, and combinations thereof. In many embodiments, the angle sensor 495 includes a three-dimensional accelerometer to determine the orientation of the treatment probe 450 in three dimensions. In many embodiments, the angle sensor 497 includes a three-dimensional accelerometer to determine the orientation of the imaging probe 460 in three dimensions. Alternatively, or in combination, the angle sensor 495 may include a goniometer to determine the angle of the treatment probe 450 along the elongated axis of the treatment probe. The angle sensor 497 may include a goniometer to determine the angle of the imaging probe 460 along the elongated axis of the imaging probe 460. The angle sensor 495 is coupled to the controller 424. The imaging probe angle sensor 497 is coupled to the processor 492 of the imaging system 490. Alternatively, the angle sensor 497 can also be coupled in combination with the controller 424.

[0277] The console 420 includes a display 425 coupled to a processor system among the components used to control the treatment probe 450. The console 420 includes a processor 423 having a memory 421. A communication circuit 422 is coupled to the processor 423 and the controller 422. The communication circuit 422 is coupled to an imaging system 490. The console 420 includes an endoscope 35 component coupled to the anchor 24. An injection / irrigation control 28 is coupled to the probe 450 to control injection and irrigation. An aspiration control 30 is coupled to the probe 450 to control aspiration. An endoscope 426 may be a component of the console 420, and the endoscope may be insertable with the probe 450 to treat a patient. An arm lock 427 of the console 420 is coupled to the arm 422 to lock the arm 422 or to allow the arm 422 to be freely movable to insert the probe 450 into a patient.

[0278] The console 420 may include a pump 419 coupled to a carrier and a nozzle as described herein.

[0279] The processor, controller, and control electronics and circuitry can include one or more of many suitable components, such as one or more processors, one or more field programmable gate arrays (FPGAs), and one or more memory storage devices. In many embodiments, the control electronics controls a graphic user interface (hereinafter "GUI") control panel to provide pre-procedure planning according to user-specified treatment parameters and to provide user control over the surgery.

[0280] The treatment probe 450 includes an anchor 24 that anchors the distal end of the probe 450 while energy is delivered to the energy delivery region 20 using the probe 450. The probe 450 may include a nozzle 200 as described herein. The probe 450 is coupled to the arm 422 using a linkage 430.

[0281] The linkage 430 includes components that move the energy delivery region 20 to a desired target location on a patient, for example, based on an image of the patient. The linkage 430 includes a first portion 432, a second portion 434, and a third portion 436. The first portion 432 includes a substantially fixed tethering portion. The substantially fixed tethering portion 432 is fixed to a support 438. The support 438 may provide a frame of reference for the linkage 430. The support 438 may include a rigid chassis or frame or housing to rigidly or rigidly couple the arm 442 to the treatment probe 450. The first portion 432 remains substantially fixed, while the second portion 434 and the third portion 436 move to direct energy from the probe 450 to the patient. The first portion 432 is fixed a substantially constant distance 438 to the anchor 434. The substantially fixed distance 438 between the anchor 24 and the fixed first portion 432 of the linkage allows for precise placement of the treatment. The first portion 434 may include a linear actuator to precisely position the high-pressure nozzle within the treatment area 20 at a desired axial location along the elongated axis of the probe 450.

[0282] The elongated shaft of the probe 450 generally extends between a proximal portion of the probe 450 near the linkage 430 and a distal end having the anchor 24 attached thereto. The third portion 436 controls the angle of rotation about the elongated shaft. During treatment of a patient, the distance 439 between the treatment area 20 and the fixed portion of the linkage changes with the reference distance 439. The distance 439 adjusts in response to computer control to set a target location along the elongated axis of the treatment probe referenced to the anchor 24. While the first portion of the linkage remains fixed, the second portion 434 adjusts the position of the treatment area along the axis. The third portion of the linkage 436 adjusts its angle about the axis in response to the controller 424, referenced to the anchor 24, allowing for very precise control of the distance along the axis at the angle of treatment. The probe 450 may include a rigid member, such as a spine, extending between the support 438 and the anchor 24 so that the distance from the linkage 430 to the anchor 24 remains substantially constant during treatment. The treatment probe 450 is coupled to a treatment component as described herein to enable treatment with one or more forms of energy, such as mechanical energy from a jet, electrical energy from an electrode, or optical energy from a light source, such as a laser source. The light source may include infrared light, a visible light beam, or ultraviolet light. The energy delivery region 20 may be moved under the control of the linkage 430, such as to deliver a desired form of energy to the patient's target tissue.

[0283] An imaging system 490, a memory 493, communication circuitry 494, and a processor 492. The processor 492 in corresponding circuitry is coupled to the imaging probe 460. An arm controller 491 is coupled to the arm 444 to precisely position the imaging probe 460.

[0284] FIG. 14A illustrates a multi-purpose sheath and manifold, according to an embodiment. The manifold 468 is configured to transfer multiple fluids to and from a work site. The manifold 468 is rigidly coupled, e.g., affixed, to the spine 452. The sheath 458 can be positioned around the spine 452 and extend inward toward the manifold 468. The manifold 468 is coupled to the support 438 in the linkage 430 using a locking element 460. The manifold 468 can be decoupled from the linkage 430 and the support 438 to remove the linkage 430 and the support 438 and allow additional components to be inserted into the working channel. For example, an endoscope can be inserted into the working channel to extend toward a working area of ​​an organ, e.g., the prostate. A structure 462 including a protruding portion extends toward the manifold 468. Structure 462 is shaped to engage manifold 468 and allow removal of structure 462, linkage 430, and support 438 when locking element 460 is disengaged. Manifold 468 includes structure 464 that engages with a protruding portion of structure 462. Multiple seals are disposed on manifold 468 to allow removal of structure 462. When structure 462 is removed, an endoscope or other surgical tool can be inserted into the working space and advanced toward the treatment site. For example, an endoscope can be advanced toward the treatment site, which will be the treatment area. The manifold includes multiple ports that are coupled to and removed from the treatment site to allow fluid to be transferred therethrough, for example, when an endoscope is positioned at the treatment site. The locking element and manifold allow removal of the linkage and treatment probe such that manifold 468 remains coupled to sheath 458 and spine 452 within the patient.

[0285] In many embodiments, a treatment probe and carrier as described herein, e.g., a tubular carrier, can be inserted and removed while locking element 460 engages linkage 430 and support 438. This configuration of linkage, locking element, and support allows the probe to be quickly and easily removed and reinserted to provide beneficial treatment.

[0286] Multipurpose sheaths and manifolds as described herein have the benefit of allowing the sheath, manifold, spine, and anchors to remain attached to the patient while additional surgical tools are employed. Locking elements interface with multiple instruments, allowing for placement, visualization, and aquablation and aquabeam operation without reintroduction or movement relative to tissue. Multiple sealed conduits allow sheath ports to be used to transmit various fluid flows or pressures within or parallel to the working channel. The working channel may be used for visualization access to anatomy via existing rigid or flexible endoscopic techniques. The working channel has a large diameter to accommodate many types of tools and allow for free flow of tissue and fluids. Alternative energy delivery devices may be used within a sheath or working channel as described herein.

[0287] In many embodiments, the working channel is sized to allow for multiple carriers within the working channel, for example, an endoscope carrier within the working channel and a treatment probe carrier as described herein within the working channel to allow visualization of the treatment site while the treatment probe is performing aquablation and aquabeam operations as described herein.

[0288] FIG. 14B illustrates a manifold conduit of a manifold configured to transmit and receive multiple fluids while the manifold remains coupled to a patient. The manifold is coupled to multiple ports 456. The multiple ports 456 may include an auxiliary fluid port 456A, a balloon pressure port 456B, and a tissue removal port 456C. A sheath 458 extends circumferentially around the spine 452. The spine 452 and sheath 458 are rigidly coupled to the manifold portions and can provide connections and channels coupled to the manifold portions. A channel 467, e.g., a tubular channel, is connected to port 456B to enable balloon inflation. A channel 469 can be defined with the sheath 458. The channel 469 can be coupled to port 456A to provide auxiliary fluid to the treatment site. A port 456C, which enables tissue removal, can be coupled to a main working channel 465. The main working channel 465 can extend from port 456C to the treatment site. A plurality of seals 466 are positioned to separate the treatment ports and channels as described herein. Manifold 468 can be decoupled from linkage 430 and support 438 to allow balloon inflation pressure to be applied through port 456B. Auxiliary fluid can be provided through port 456A, for example, to flush working channel 465. This configuration of the manifold allows spine 452 and anchors 24 to remain in place when other instruments are inserted into the working channel.

[0289] Multiple manifold conduits as described herein allow tissue collection to be routed through large diameter working channel 469 to reduce flow obstruction. Balloon pressure can be transmitted from the luer fitting to the distal tip of the anchor with a small diameter tube, for example, the tube that defines channel 467. Auxiliary fluid is transmitted to the treatment area between the sheath and spine using channel 469.

[0290] FIG. 14C shows the treatment probe and linkage components disassembled prior to use. Linkage 430 includes a casing 410 and a cover 412. The cover 412 can be disposed over a lower portion of the casing 410. The cover and casing can include a rigid material to add rigidity. The casing and cover can be sized to include a handpiece containing linkage 430. Linkage 430 includes an elongated tubular structure including a gear 433 that engages with another gear 434 of the linkage. Gear 434 can be positioned on a movable carriage 413. The elongated tubular structure can include a second movable portion 436 of the linkage. Casing 410 can include a support 438 for the linkage. Gear 433 remains connected to elongated tubular structure 431 when the linkage is disassembled. The movable portion of linkage 430 may include gear 433, gear 434, and movable carriage 413 to advance elongated structure 431 distally when connected to a second movable portion 436 as shown by arrow 418. Cover 412 includes flange 416. When the cover is placed over the casing, the elongated structure can be locked into position 431 on the linkage.

[0291] Elongated element 310 includes spine 452 as described herein and is shown covered by sheath 458. Sheath 458 includes a channel to receive elongated element 310. Elongated element 310 includes a working channel and can be inserted into sheath 458 such that the elongated element is covered by sheath 458. Sheath 458 and elongated element 310 are shown connected to manifold 468 as described herein.

[0292] The sheath 458 can be inserted into the patient prior to the insertion of the elongate element 310. In many embodiments, the sheath 458 is coupled to the manifold 468 when inserted into the patient.

[0293] Elongated element 310 is configured to slide into sheath 458 such that elongated element 310 and the sheath include a locking configuration. Elongated element 310 includes structure 411 configured to engage linkage housing 410 such that elongated element 310 and housing 410 remain substantially fixed when elongated structure 431 moves as described herein.

[0294] In many embodiments, the casing 410 includes a support 438. The support 438 may comprise a substantially stationary portion of the linkage 430, as described herein. The linkage 430 may comprise a moving carriage 433 to move the carrier 382 when the casing 410, including the support 438, is locked to the arm and remains substantially stationary, as described herein.

[0295] In many embodiments, the structure 411 of the elongate element 310 includes a locking structure so as to form a locking joint with the casing 410 and the cover 412 .

[0296] In many embodiments, manifold 468 can be connected to sheath 458 and affixed to the sheath such that sheath 458 can be inserted into a patient and manifold 468 can be used to inflate balloon anchor 24, as described herein. Elongated element 310 including spine 452 can then be inserted into sheath 458. Manifold 468 and structure 411 include locking structure 417 to lock manifold to elongated element 310 when elongated element 310 is inserted into manifold 468 and sheath 458. Release 415 can be pressed by a user to release manifold 468 from elongated element 310.

[0297] The elongated tubular structure 431 of the linkage 430 includes structure for receiving the carrier tube 380. An opening 409 in the elongated tubular structure 431 is sized to receive the carrier tube 380. A connecting structure 408 is shown on the proximal end of the linkage and includes a locking structure 406 for receiving the protrusion 404 of the connecting structure 405 of the carrier tube 308.

[0298] 14D1 illustrates rapid exchange of carrier tube 380 when linkage 430 is coupled to elongate element 310 anchored at a target location in an organ. Elongate element 410 can be inserted or removed from linkage by a user. Elongate element 380 can be advanced into opening 409 near connecting structure 405 of elongate tubular structure 431.

[0299] The imaging probe 460 can be mounted on a second linkage and configured to move with the nozzle of the carrier 382 to image the interaction of the energy stream from the carrier 382 as tissue is treated. The images of the treatment may comprise axial and sagittal images from the imaging probe 460. The linkage can be coupled to a controller or processor (or both) as described herein to, for example, move the imaging probe 460 synchronously along an axis with the carrier 382 and the nozzle of the carrier. The imaging probe 460 may comprise a transrectal ultrasound probe, and the carrier 482 may comprise components of the treatment probe 450 as described herein.

[0300] FIG. 14D2 shows the alignment of the distal tip of carrier 382 with opening 409 at the proximal end of elongated tubular structure 431 for insertion of carrier tube 380 as in FIG. 14D1.

[0301] 14D3 shows the carrier advanced toward locking structure 406 on the proximal end of the linkage as in FIG. 14D1. Locking structure 406 is sized to receive protrusion 404 to form locking joint 402.

[0302] Figure 14D4 shows carrier tube 380 locked to linkage 430 as in Figures 14D1 and 14D2. Protrusion 404 is inserted into opening in locking structure 406 to form a locking joint. The joint can be released by user action.

[0303] 14E shows a cystoscope at least partially inserted into a sheath 458 for advancement toward an anchoring location in an organ. The anchoring location may include the bladder neck to visualize the tissue of the organ, such as the prostate. A sheath 458 as described herein can be advanced to the target location using visualization from a cystoscope positioned within the working channel of the elongate element 310. When positioned, an anchor 24, such as a balloon, can be inflated using a port in a manifold 468 coupled to the sheath as described herein.

[0304] There are at least two forms of visualization possible with the embodiments described herein: 1) A cystoscope is locked within sheath 458. The goal may be to visualize the prostate and then ultimately leave the sheath as a safe channel to guide elongated element 310, including spine 452, into the patient, in many embodiments without direct visualization. The distal end of the sheath is lined up near the bladder neck. 2) Once elongated element 310 is locked into sheath 458, a ureteroscope can be used to visualize the patient. The ureteroscope can be inserted inside the same channel where carrier 380 enters, for example, a shared channel.

[0305] 14F shows the advancement of elongate element 310 into sheath 458. Manifold 468 on the proximal end of sheath 458 may include a locking structure to receive the locking structure on the proximal end of elongate element 310. Elongate element 310 may be advanced into sheath 458 such that the locking element on sheath 458 and elongate element 310 engage.

[0306] 14G shows linkage 430 coupled to elongate element 310 including spine 452. Linkage is configured to receive carrier 382 and carrier tube 380 as described herein.

[0307] FIG. 14H shows the carrier tube and carrier inserted into the chain tube in a locked configuration as described herein.

[0308] 14A-14H illustrate a method of treating a patient, according to an embodiment, each of which illustrates one or more optional steps of the method.

[0309] 15 and 16 illustrate self-cleaning using a fluid jet as described herein. A fluid jet, such as a fluid stream as described herein, can be utilized to clean the working channel and remove tissue or other debris within the multi-function sheath. Self-cleaning can be automated or manual. Additionally, the water jet intensity can be reduced to clean a laser camera or other accessory device without the need to remove the device from the working channel. For example, an endoscope can be sized to fit within the working channel, or alternatively, the endoscope can be sized to fit within the working channel with the linkage broken and to allow cleaning and irrigation of the working channel. Alternatively, or in combination, a carrier 382, ​​which may comprise a carrier tube 380, can be sized to fit within the working channel together with the endoscope to allow cleaning of the endoscope.

[0310] In many embodiments, self-cleaning can be employed with a probe including a carrier 382, ​​which may comprise a carrier tube 380 positioned within the working channel. The elongate element 310, including the sheath and spine, can contain a carrier 382, ​​which may comprise the carrier tube 380 along a majority of the carrier. The carrier 382 may comprise rectangular or tubular end portions, for example, and may comprise portions having cylindrical and tubular geometries. The fluid stream emitted from the carrier 382 can extend a distance 457, for example, with divergence. Alternatively, the fluid stream can comprise a columnar fluid stream. The angle of the fluid stream 453 can be controlled using a linkage to rotate the fluid stream during cleaning. The fluid stream can be increased or decreased in terms of pressure.

[0311] The fluid jet can be utilized to cleanse the working channel and remove tissue or other debris within the multi-function sheath. This can be automated or performed manually. Additionally, the water jet intensity can be reduced to clean a laser camera or other accessory device without the need to remove the device from the working channel.

[0312] FIG. 17A illustrates components of a user interface 500 on a display 425 of the system 400. The display 425 may comprise, for example, a touchscreen display; alternatively, or in combination, the display 425 may be coupled with a pointing device, keyboard, and other known user input devices to cooperate with the processor system. The interface 500 includes an operations tab 502, a CO2 monitor tab 504, and a system configuration tab 506. The user interface 500 includes buttons 507 on the display to adjust values ​​entered into the computer system up or down. A stop button 503 is provided on the user interface for a user to stop treatment of a patient. A start button 501 is provided for a user to start treatment of a patient. The user interface 500 includes an image 510 of an organ, such as the prostate. The image 510 shown can be one or more images of many organs as described herein. The image 510 may comprise, for example, an image of the prostate from an anatomical image corresponding to the patient's prostate. The image 510 is shown in an axial cross-sectional view having an anterior and posterior orientation, and the image 510 is also shown along the longitudinal axis. A sagittal view of the image 510 along the longitudinal axis shows the anchor 24 and a lumen such as the urethra. The image 510 may comprise an image of the patient being treated, for example, an ultrasound image of the patient. The image 510 can be shown in axial and sagittal views, with the ultrasound image sized to correspond to the treatment profile shown on the display 425.

[0313] The treatment profile 520 is shown in axial and sagittal views. The treatment profile 520 corresponds to the profile of tissue removed within the surface remaining after removal. The treatment profile 520 includes a radius 522 extending from a central reference location to an outer portion of the cut tissue boundary. The treatment profile 520 includes an outer component 524 extending circumferentially around the treatment axis. The treatment profile 520 extends from a first end 526 proximal to the bladder and anchor to a second end 528 toward the urethra. The treatment profile image shown on the display includes multiple references to align the treatment to the patient's anatomy. An axis 530 corresponds to the center location of the treatment and extends axially along the patient's lumen, such as the urethra. The treatment axis 530 may correspond to a patient's anatomical reference, such as the urethra or the pathway through which an instrument is introduced into the patient. An angular reference 532 is shown extending from the central axis of the treatment profile to the outer radial boundary of the treatment profile 534. The angle component 532 corresponds to an anterior-posterior position on the patient component and extends from anterior to posterior to a position 534 to provide and allow alignment with the patient. As can be seen in the sagittal view, the treatment reference position 536 corresponds to a position adjacent to an expandable anchor, such as balloon 24. The reference position 536 corresponding to the expandable anchor is shown aligned with the end 526 of the treatment profile 20, where the treatment profile is shown aligned with the axis 451 of the treatment probe.

[0314] The user interface 500 includes a number of inputs, which may comprise one or more of the following inputs, as described herein:

[0315] The plurality of angular input parameters 550 may comprise, for example, input 552 and input 554. The angular orientation can be set to align with the patient's anterior-posterior direction extending between axis 530 and marker 534. Input 552 can be used to adjust the angular orientation of the treatment about axis 530, for example, if the patient and probe are aligned at a slightly different angle. Input 552 rotates about the axis to align the center of the treatment profile in degrees. Input 554 provides a sweep angle from one angular extreme to another; for example, the sweep angle may comprise an angle less than 360°, e.g., 240°. The sweep angle generally extends about the anterior-posterior treatment axis, extending approximately half the distance of the sweep angle to the anterior-posterior treatment axis, e.g., sweeping 120° in a first direction and sweeping 120° in an opposite direction from the anterior-posterior treatment axis. In many embodiments, the sweep angle is limited to less than 360 degrees to avoid sweeping the fluid flow into the spine.

[0316] The angular position of the flow can be shown in real time on a display with the angular position in degrees output 556. The output angle can be shown on the display as a moving colored line, e.g., green, sweeping around axis 530.

[0317] A number of input parameters 560 can be used to determine the extent of treatment along axis 451 and axis 530. Input 562 determines the location of the treatment profile relative to expandable anchor 24. Input 564 determines the length of treatment along axis 451 and axis 530. Input 564 may comprise the longitudinal distance of the treatment extending from first end 524 to second end 528. Input 570 can determine the radius of the treatment profile about axis 530. Input 570 is the radial distance from axis 530 radially outward to the outer boundary of treatment profile 524. The radius may comprise the radial distance in millimeters, such as a distance of 10 mm. Alternatively, the radius can be determined by the power of the pump, which can be set at an arbitrary value, for example, from 1 to 10.

[0318] A select mode input 508 can allow a user to set the interface, for example, from cut mode to coagulation mode. In cut mode, many of the inputs for the treatment can be provided to determine and align the treatment with the patient. In cut mode as shown, the user can visualize the extent of the treatment in relation to the patient's anatomy and develop and refine the treatment strategy. The user can establish a cut profile with a predefined profile surface and a predefined removal volume.

[0319] The patient interface may include additional outputs for the user to determine the appropriate treatment, such as time remaining in treatment, allowing the user to determine the duration of treatment, with output 580 indicating the time remaining in seconds. Output 582 may include an estimated volume of tissue removal, where the estimated volume of tissue to be removed may be determined based on the treatment profile. An estimated radial depth of removal may also be determined, with output 584 indicating the estimated radial depth of removal. The estimated depth of removal may comprise the input radius from input 570, or alternatively, the estimated depth may correspond to the estimated depth from the pump power at input 570. A start button input 501 allows the user to begin treatment when the physician is satisfied with the patient treatment. When insufflation, e.g., with a gas such as CO2, is used, the insufflation pressure may be set with input 586. Alternatively, when a liquid is used as the second or first fluid in combination with another liquid as described herein, the insufflation pressure may be set to zero or disabled. In many embodiments, insufflation may be set to zero in a first mode, such as a cutting mode, and set to an appropriate value in a second mode, such as a coagulation mode.

[0320] 17B and 17C show markers moving across multiple images, where the movement of the markers corresponds to the position and orientation of the energy flow. The energy flow may comprise a fluid flow from a nozzle, as described herein. A radial marker 557 is shown on the axial image with respect to the ablation profile 520. A longitudinal marker 559 is shown on the sagittal image with respect to the ablation profile 520. The radial marker 557 is shown at a first angle in FIG. 17B and a second angle in FIG. 17C to indicate the angle of fluid flow from the carrier, for example, as described herein. As treatment progresses, the longitudinal marker 559 can move along the treatment axis on the sagittal image to indicate the longitudinal position of the nozzle on the carrier as the radial marker 557 rotates around the axis on the axial image.

[0321] 17D shows a user-defined cutting profile 520. The user interface can be configured with processor instructions to allow a user to define multiple points of a treatment profile and to interpolate between the points, as described herein.

[0322] 17E and 17F show a user interface for defining multiple curved portions of a cutting profile. A first user movable input 551 can be configured to move along on the display and define a first curved portion of the profile 520, a second user movable input 553 can be configured to move along on the display and define a second curved portion of the profile 520, and processor instructions can be configured to interpolate between the first and second curved portions to define a profile 529 extending between the first and second curved portions, for example. A first end 526 of the treatment profile can be set based on the user input, and a second end 528 can be set based on the user input as described herein. A user can slide the first movable input 551 to determine the curved shape of the first portion based on the engagement of the cutting profile with the end 526 and the location of the movable input 551 on the display. For example, a first curved shape may be determined using a spline fit extending from the first input to the end 526, constrained by the angle at the end 526 and the movable input 551. A second movable input 553 may be similarly moved to define, for example, a second curved shape for the second portion.

[0323] FIG. 18 shows the system configuration mode 506 for the cutting mode input 508. When the system configuration is set, the user can set several parameters of the treatment prior to or during treatment to align the treatment profile with the patient and ensure that the treatment probe 450 cuts tissue as intended. One or more inputs 590 allow the user to align the intended treatment with the probe placed in the patient. The one or more inputs 590 may include an input 591 to set the treatment to zero and align the treatment axis with the patient's axis; for example, an intended anterior-posterior treatment profile may be aligned in the anterior-posterior direction of the patient such that the anterior-posterior axis of the treatment profile is aligned with the anterior-posterior axis of the patient. The input 591 may be set based on one or more measurements, for example, ultrasound imaging measurements, to determine that the probe is properly aligned with the patient. Alternatively, or in combination, the input 591 may be set based on an angle sensor as described herein. The one or more inputs 590 may include an input 592 to set the treatment to zero axially and align the treatment probe with the patient's intended anatomical target. Input 592 allows for alignment of the longitudinal axis with the patient's intended target location; for example, if the treatment probe 450 is placed insufficiently far or too deep, the zero z button can be pressed so that input 592 zeros the treatment at the correct anatomical location.

[0324] The system configuration mode can also be used to set up and calibrate the system. For example, input 598 can enable the zero angle of a first angle sensor, e.g., the angle sensor of the treatment probe 450, to be set to zero and properly aligned. Input 599 can be used to set the imaging probe sensor to the proper angle, e.g., to calibrate the imaging probe.

[0325] Input 595 can allow a user to select from among multiple probe types, for example, a probe type may include multiple nozzle types, for example, a fourth nozzle type may include a narrower nozzle diameter to allow treatment at a greater radial distance from the axis of the treatment probe 450. In the system configuration mode for a given profile, a user can select multiple probe types to determine the time remaining, estimated volume, and estimated depth based on the identified probe and, for example, the nozzle size of the selected probe.

[0326] 17A and 18 may refer to a divergent cutting screen in which the first fluid comprises a liquid and the second fluid comprises a liquid. Alternatively, gas can be used to provide a protective jacket around the treatment beam in the treatment stream to extend the effective cutting distance of the treatment probe 450. The system may include instructions to perform a portion of the treatment using one configuration of the first fluid and the second fluid and a second configuration of the first fluid and the second fluid, to cut a second portion of the treatment using the gas protecting the treatment stream.

[0327] In many embodiments in which the sweep angle is limited to less than 360 degrees to avoid the spine as described herein, a first treatment can be performed at a first angular orientation of the probe about the axis, the probe can be rotated to move away from the spine to expose the untreated portion to the flow, and a second treatment can be performed. The angle of the probe for the first treatment can be measured, the angle of the probe for the second treatment can be measured, and the treatments can be rotated to treat the untreated portion based on the first and second angles. For example, the first treatment can comprise a 240-degree sweep and the second treatment can comprise a 120-degree sweep so that the entire treatment extends substantially around the axis of the probe to a greater angle than would be provided if the spine had not been rotated to expose the untreated portion. The probe can be rotated to a second measured angle, e.g., 70 degrees, and the second treatment can be performed with a 120-degree sweep. The center position can be adjusted by input 552 or software so that the second treatment is aligned with the untreated portion.

[0328] FIG. 19 shows the coagulation mode selected with input 508. The operation tab selected with input 502 can be used to configure the treatment for coagulation. Coagulation can be provided in many ways, for example, using divergent or columnar flow, and combinations thereof. In many embodiments, it may be desirable to treat only a portion of the treatment profile with coagulation. For example, the posterior portion of an organ, e.g., the prostate, can be selectively treated with coagulation. Work related to the embodiments suggests that posterior treatment may potentially result in slightly more bleeding, and in some embodiments, it may be advantageous to selectively treat the posterior portion of the patient's anatomy, e.g., the prostate. In coagulation mode with a laser beam, the treatment input parameters are similar to those described above for cutting. The sweep angle can be set using input 554, for example, to a value of 100°, with the sweep angle for coagulation being smaller than the sweep angle for cutting. The remaining treatment time 580 can be shown, and the user may also view the volume of the treatment, e.g., the coagulation volume. The user is also allowed to select the laser power using input 575 and position the treatment similar to that done with cutting, although the angular range may be smaller and the longitudinal range may be smaller or larger, for example.

[0329] The input treatment profile can be input in one or more of many ways; for example, an image of the organ to be treated, e.g., the prostate, can be provided, and the user can draw the intended treatment profile on the patient's axial and sagittal images. The images shown may comprise anatomical images corresponding to the anatomy of a generalized population, or alternatively, the images shown may comprise images of the patient. The processor system includes instructions to map and transform the reference treatment profile on the image of the patient to the machine coordinate references of the treatment probe 450 and linkages 430 and anchors 24 as described herein. In many embodiments, the image shown to the user is scaled to correspond to the treatment profile so that the treatment profile shown on the image of the anatomical organ to be treated corresponds to and aligns with the treatment dimensions of the image. This allows the user to accurately determine and place the intended treatment profile on the patient.

[0330] FIG. 20A illustrates the mapping and alignment of a patient image with a treatment coordinate reference frame. An image 510 of an organ can be obtained in one or more of many ways, as described herein. The image may have an image reference frame, including, for example, X, Y, and Z coordinate references. The treatment probe 450 includes a treatment reference frame, e.g., cylindrical coordinate references R, Z, and Theta. The orientation of the probe's axis can be determined as described herein. To align the two images with a common known reference point, a marker reference 536, such as a treatment probe anchor, can be identified from the image. Image points from the image reference frame can be mapped to the coordinate reference frame and shown on the display based on the location of the identified reference point and the orientation of the probe. A point in the image with image coordinate references of (X1, Y1, Z1) can be mapped to the treatment reference frame to provide a treatment reference position (R1, Z1, T1). For example, three-dimensional mapping of patient tissue can be performed similarly.

[0331] Three-dimensional mapping of the tissue of a target organ can be performed, and the three-dimensional mapping can be used to provide a three-dimensional profile of the target organ. For example, multiple sagittal and axial views of the three-dimensional profile of the organ can be provided, and a user can draw a target treatment profile on each of the multiple sagittal and axial views to provide a customized treatment for the patient. In many embodiments, the processor includes instructions for interpolating the treatment profile between the sagittal and axial views to provide a mapped three-dimensional treatment profile. In many embodiments, additional tissue removal can be provided by providing additional treatment inside the prostate, and mapping as described herein can be used to provide additional removal of an inner portion of the prostate tissue.

[0332] In many embodiments, a user can identify multiple points of a treatment profile on a screen of the patient's tissue, and the multiple points are mapped to a treatment coordinate reference and shown on the display so that the user can verify that the treatment coordinates of the treatment profile shown on the display are treating the target tissue as intended by the user.

[0333] FIG. 20B illustrates a method 600 for treating a patient.

[0334] In step 602, a calibrated treatment probe as described herein is provided.

[0335] In step 605, an image of an organ (eg, a prostate) as described herein is provided.

[0336] In step 607, a reference structure for the treatment probe as described herein is provided.

[0337] In step 610, the reference structure is aligned with the image of the organ as described herein.

[0338] In step 612, the organ image coordinates are mapped to treatment reference coordinates as described herein.

[0339] In step 615, the image coordinates are scaled to treatment reference coordinates as described herein.

[0340] In step 617, the image of the organ aligned with the reference structure is displayed as described herein.

[0341] In step 620, treatment input parameters are received as described herein.

[0342] In step 622, a tissue ablation profile is determined based on the input parameters, as described herein.

[0343] In step 625, the tissue ablation profile is displayed over the organ image as described herein.

[0344] In step 627, the tissue ablation profile and location are adjusted based on the image, as described herein.

[0345] In step 630, ablation parameters are determined as described herein.

[0346] In step 632, a treatment nozzle is identified from among the plurality of treatment nozzles, as described herein.

[0347] In step 633, a carrier is identified from among multiple carriers as described herein.

[0348] In step 635, the type of fluid flow is selected as columnar or diverging, as described herein.

[0349] In step 637, a first fluid and a second fluid are selected as described herein.

[0350] In step 640, a treatment probe is inserted into the patient as described herein.

[0351] In step 642, the treatment probe arm is locked as described herein.

[0352] In step 645, an imaging probe is inserted into the patient as described herein.

[0353] In step 650, the imaging probe is locked as described herein.

[0354] In step 657, the imaging probe is moved relative to the treatment probe as described herein.

[0355] In step 660, the alignment of the treatment probe with the patient is determined as described herein.

[0356] In step 662, the orientation of the treatment probe is measured as described herein.

[0357] In step 665, the orientation of the treatment probe is measured as described herein.

[0358] In step 667, the planned treatment is adjusted based on the patient alignment, as described herein.

[0359] In step 668, the patient is treated as described herein.

[0360] In step 670, the tissue to be treated with the planned treatment is imaged and viewed as described herein.

[0361] In step 672, the jet entrainment "fluid flame" is visualized as described herein.

[0362] In step 675, the jet entrainment "fluid flame" interaction is viewed as described herein.

[0363] In step 677, additional tissue is ablated based on the viewed image, as described herein.

[0364] In step 680, the therapy is adjusted as described herein.

[0365] In step 682, the elongate element and sheath are rotated about the elongate axis to rotate the spine, as described herein.

[0366] In step 685, the angles of rotation of the elongate element and spine are measured as described herein.

[0367] In step 687, the treatment profile is rotated about an axis based on the measured angle. For example, the treatment profile may be rotated about an elongate axis of the treatment profile that corresponds to the elongate axis of the elongate element and spine and sheath, as described herein.

[0368] In step 690, the portion of the organ blocked by the spine as described herein is treated.

[0369] In step 695, treatment is completed as described herein.

[0370] The above steps illustrate a method 600 for treating a patient, according to an embodiment, although one skilled in the art will recognize many variations based on the teachings described herein. Steps may be completed in a different order. Steps may be added or removed. Some of the steps may comprise sub-steps. Many of the steps may be repeated as often as beneficial to the treatment.

[0371] One or more of the steps of method 600 may be performed using one or more of a processor or logic circuit, such as a circuit as described herein, e.g., a programmable array for a field programmable gate array. The circuit may be programmed to provide one or more of the steps of method 600, and the program may comprise program instructions stored on a computer-readable memory or programmed steps of a logic circuit, e.g., programmable array logic or a field programmable gate array.

[0372] 21A and 21B show screenshots of organ images, e.g., transrectal ultrasound prostate images, from 3D segmentation software according to an embodiment of the present invention. Two-dimensional images are shown on the right side of FIGS. 21A and 21B, respectively. Three-dimensional images of the prostate are shown on the left side of FIGS. 21A and 21B, respectively. The two-dimensional images on the right side of FIGS. 21A and 21B show examples of transverse and sagittal planes of the three-dimensional prostate representations shown together with the images on the left side of FIGS. 21A and 21B, respectively. Transverse images may also be referred to as horizontal, axial, or transverse slice images, as described herein. Note that the segmentation of the sagittal plane of the prostate is depicted in light gray, and the segmentation of the axial plane of the prostate is depicted in light gray.

[0373] These segmented images can be provided on a display for a user to plan treatment of an organ, along with an image of the treatment superimposed on an image of the organ as described herein, such as a treatment profile superimposed on an image of the prostate.

[0374] 21A and 21B may be provided on the display 425 of the interface 500. For example, axial and sagittal images may be provided on the display as described herein.

[0375] 21C-21F show multiple axial images 525 of a target tissue for defining a three-dimensional treatment plan and a user-defined treatment profile within each of the multiple images. The user interface includes a first tab 527 for selecting a Z-slice view of a three-dimensional representation of the target tissue, such as an organ that may include a prostate, and a second tab 529 for selecting a Y-view. The Z-slice view may correspond to a sagittal view of the target tissue, and the Y-slice view may correspond to an axial view of the target tissue. The multiple axial images include a first image 525A in a first z-frame 523. The z-frame 523 may correspond to a location along an axis traversed by the y-slice view, and each z-frame may correspond to a location in the axial image along the z-axis. The first z-frame may be one or more of many frames.

[0376] Each image 510 includes a user-inputted treatment profile 520. The user-inputted treatment profile may comprise a plurality of points that are user-adjustable on the image to define the treatment profile. A first plurality of images 525A shows a treatment profile partially positioned by the user, with a plurality of treatment profile marker points 521 not yet placed by the user at the target tissue location. The user can adjust the location of the points in a user interface, for example, using a pointing device or a touchscreen display. A processor as described herein includes instructions for receiving a plurality of points input by a user. The plurality of points may comprise small user-movable markers, such as circles, dots, or Xs, and the plurality of points can be connected with a line in one or more of a number of ways, such as, for example, using linear interpolation to connect the markers, corresponding to a straight line shown on the display, or a spline to connect the markers, corresponding to a curve shown on the display.

[0377] A second image 525B of the plurality of images at a second depth is shown on the display as described herein, and includes a point 521 that is aligned with the image by the user to define a treatment profile 520 at a second location along the z-axis corresponding to the treatment.

[0378] A third image 525C of the plurality of images at a third depth is shown on the display as described herein, and includes a point 521 that is aligned with the image by the user to define a treatment profile 520 at a third location along the z-axis corresponding to the treatment.

[0379] A fourth image 525D of the plurality of images at a fourth depth is shown on the display as described herein. The fourth image 525C includes a point 521 that is aligned with the image by the user to define a treatment profile 520 at a fourth location along the z-axis corresponding to the treatment.

[0380] Figure 21G shows a sagittal view of the target tissue and a plane of the axial images of Figures 21C-21F. The z-slice view can be selected with tab 527 to show a sagittal view of the target tissue. Multiple images 525 are shown as lines extending through the sagittal view.

[0381] FIG. 21H shows a three-dimensional treatment profile based on the multiple images of FIGS. 21A-21F. The three-dimensional treatment plan may comprise a three-dimensional representation of the three-dimensional treatment profile 520. The three-dimensional treatment profile 520 can be determined in one or more of many ways. The three-dimensional treatment profile may be obtained by interpolation between multiple points 521 that define the treatment profile for each image, for example, by linear interpolation of a spline. Alternatively, or in combination, the three-dimensional treatment profile can be determined based on, for example, a polynomial fit to the surface points 521.

[0382] 21I shows a user-input treatment profile for an image among multiple images as described herein. The user can adjust the multiple points 521 in one or more of many ways, and the user can determine the treatment profile based on the patient's needs. The treatment profile can be selected so that it does not extend to the outer boundaries of tissue structures, for example, the outer structures of an organ such as the prostate gland as shown in FIG. 21I.

[0383] FIG. 21J illustrates a scan pattern for a fluid stream as described herein. The fluid stream may comprise a pulsed or continuous fluid stream. The scan pattern can be based on a critical pressure as described herein to remove a first tissue and prevent removal of a second tissue. In many embodiments, the fluid stream includes multiple pulses 810 from a pump, such as a piston pump, where the pulses include a frequency and a duty cycle. In many embodiments, the duty cycle corresponds to no more than about 50%. The multiple pulses 810 include a first pulse 812 and a second pulse 814. The fluid flame may have an approximate cross-sectional size at the location of the tissue being scanned. Based on the teachings described herein, one skilled in the art will recognize that the fluid flame includes a maximum cross-sectional width at about half the length of the fluid flame. At the location where the fluid flame impacts the tissue, the fluid flame includes a cross-sectional size 848.

[0384] The scan pattern of the fluid stream including the fluid flame is along the Z axis and angle 844. The angle 844 may correspond to time 845, e.g., when the angular sweep rate remains substantially constant. The fluid flame is scanned along scan path 846. The scan path 846 may correspond, e.g., to the velocity of the carrier 382 along the Z axis and the rotation of the carrier 382 about the Z axis.

[0385] The pulses can be spaced so that multiple consecutive pulses strike tissue location 830. Multiple consecutive pulses can be effective in removing a first type of tissue while preventing removal of a second type of tissue.

[0386] Alternatively, or in combination with critical pressure as described herein, work related to embodiments suggests that the rate of removal may be related to the relaxation time of the target tissue. The fluid flame can be configured to dwell over the tissue point 830 for a duration longer than the tissue's relaxation time, such that the fluid flame can deform and remove the tissue beyond a threshold.

[0387] In many embodiments, the multiple pulses 820 affect the tissue location 830 with a duration between pulses that is less than the tissue relaxation time of the elastic deformation of the tissue to remove the tissue. In many embodiments, the first tissue to be removed includes a first relaxation time that is longer than the time between pulses, and the second tissue to be prevented from removal includes a second tissue relaxation time that is less than the time between pulses to prevent removal of the second tissue.

[0388] As tissue is removed toward the final desired treatment profile, the size of the fluid flame may be substantially reduced near the distal tip of the flame such that the size of the pulsed fluid flame affecting the ablated profile is substantially reduced and tissue removal is substantially reduced.

[0389] Based on the teachings described herein, one skilled in the art can determine the scanning movement of the carrier 382 and nozzle to ablate tissue to a target profile using the fluid flame described herein.

[0390] FIG. 21K shows a bag covering the fluid stream. The fluid stream may comprise a columnar flow or a diverging flow, as described herein. In many embodiments, the bag is placed over the fluid stream, including the pulsed flow, to induce a water hammer effect. The bag can be made of one or more of a number of materials and may include, for example, an elastomer. The interior of the bag can be coupled to the carrier 382, ​​and the exterior of the bag can be coupled to the working channel to remove material. The bag can have the advantage of protecting the tissue from high fluid flow rates and can also provide uniform pressure. The fragmented tissue can be collected through passive or active means, for example, through an outer collection tube or the working channel.

[0391] 22A and 22B show schematic diagrams of a probe being operated according to the principles of an embodiment as described herein to provide real-time determination of a tissue removal profile 520. Fig. 22A shows a columnar fluid flow 331, and Fig. 22B shows a diverging flow 334, each of which is suitable for combination with image-guided tissue ablation as described herein.

[0392] Interstitial laser-guided 3D imaging (with or without fluid, and with or without a water jet, inside tissue and / or inside an organ) employs a spot from a laser on the inner surface of the prostate to determine the depth of ablation. That is, knowing the axial and rotational position of the nozzle and considering that the spot is located on a radius from the nozzle, locating the spot in the image from the camera yields a unique spot-to-nozzle distance. Scanning the laser and using image processing to find the spot can generate a full image of the prostate's inner volume. This can be combined with organ geometric data to display the volume to be ablated within the organ in 3D. Alternatively, the laser can be used to measure the distance between itself and the target surface, recreating an exact 3D replica of the area it scanned.

[0393] Acoustic Distance Measurement

[0394] By placing an acoustic transducer in the assembly near the water jet, it would be possible to measure the distance along the water jet to the tissue surface struck by the jet. Scanning the jet would then allow for three-dimensional mapping of the cavity. At least one transducer 392 could be provided on the carrier tube 380. Intra-tissue sound-guided tissue differentiation (inside tissue and / or inside organs in a fluid / gas environment): The audio frequencies generated by the jet-tissue interface could enable tissue differentiation. Monitoring the acoustic behavior at this interface could add a depth monitoring feature to the system, which could enhance safety by preventing the jet from penetrating the prostate capsule. The sensor could be mounted at the tip or anywhere along the shaft of the probe / sheath.

[0395] Pulse-width modulation of the water column: Modulating the frequency at which the water is on and off can allow the user to estimate the nozzle distance to the tissue under camera visualization. The frequency can be fixed to a predetermined column size (e.g., 5 mm), or the user can adjust it to match the height between the nozzle and the tissue, as shown in Figure 22A. Alternatively, assuming the high-pressure divergence characteristics of the nozzle are defined as shown in Figure 22B, the diameter of the jet at the jet-tissue interface can determine the distance from the nozzle.

[0396] At least one transducer 392 may comprise an acoustic transducer to receive acoustic signals from the tissue. In some embodiments, at least one transducer 392 transmits acoustic signals for ultrasound imaging. The at least one transducer may comprise multiple transducers. A second acoustic transducer may be provided on the carrier tube 380 to receive or transmit acoustic signals for ultrasound imaging from the probe to the tissue. The at least one transducer 392 may comprise an ultrasound array to provide axial and transverse images, for example, as described herein.

[0397] 22C shows an endoscope 394 positioned within the working channel of elongate element 310 with carrier 382 to image tissue. Endoscope 394 can be used to image tissue profiles as described herein. For example, the fluid stream can be used to illuminate tissue with laser pointing using a fluid stream, e.g., columnar fluid stream 331. The known angle and axial location of the fluid stream can be used along with the location of the image from the endoscope to determine the surface profile of the tissue.

[0398] 23A and 23B show a carrier configured to provide integrated jet delivery. A carrier 382, ​​which may comprise a carrier tube 380, contains an energy delivery conduit 351, such as an optical fiber. An alignment block is provided to align the optical fiber with the fluid delivery element. The optical fiber can be bent to provide a bend angle suitable for delivery of optical energy to the end of the optical fiber.

[0399] The configuration of the optical fiber, jet orifice, and alignment orifice provides integrated jetting capabilities. The jet orifice can be formed in a nozzle including an inverted solid conical section that receives a fluid to form a fluid stream and defines a conical channel that receives light from the optical fiber. The alignment orifice can be formed in the alignment structure and includes an inverted solid conical section that defines a conical channel that receives the fiber, the conical channel extending to a cylindrical channel having a diameter sized to receive the optical fiber. In many embodiments, the conical channel of the alignment orifice includes an angle that receives the fiber so that the fiber can be advanced along the conical channel and through the cylindrical channel without damaging the optical fiber. In many embodiments, the optical fiber, including the coating, has a diameter smaller than the cylindrical channel of the alignment orifice so that the optical fiber can be advanced along the conical section without damaging the optical fiber. The flat section of the alignment block can hold the fiber to prevent movement of the fiber along its longitudinal axis when the tip of the fiber is held aligned with the cylindrical portion of the jet orifice channel.

[0400] The nozzle including the jet orifice and the alignment structure including the alignment orifice may each comprise a jewel having a conical section and a cylindrical section as described herein.

[0401] In many embodiments, the cylindrical channel portion of the alignment orifice holds the optical fiber in alignment with a gap extending around at least a portion of the optical fiber, and the cylindrical channel portion of the alignment orifice extends axially a sufficient distance to align the optical fiber with the jet orifice, with the gap extending between the fiber and the cylindrical channel portion of the alignment orifice along at least a portion of the fiber and the cylindrical channel portion.

[0402] The jet orifice and the alignment orifice are axially spaced a sufficient distance so that fluid passing through the jet orifice can deliver a fluid stream of energy with a predictable flow rate, for example, to form a columnar flow with low pressure and a diverging cutting flow with high pressure. In many embodiments, the distance 351D extends between the top surface of the structure defining the cylindrical channel portion of the alignment orifice and the lower end of the cylindrical channel of the jet orifice. The distance 351D is dimensioned so that the light beam emitted from the optical fiber diverges to enable at least about 80% energy transmission through the jet orifice, for example, at least about 90% energy transmission through the alignment orifice, and to provide a predictable flow rate. In many embodiments, the distance 351D is, for example, within a range of about 200 μm to about 2.5 mm, for example, within a range of about 0.5 mm to about 2 mm.

[0403] An alignment block is coupled to the optical fiber, and the alignment block includes a surface that engages the optical fiber, the fiber engaging surface including a radius of curvature that may be less than 5 mm, for example, no more than 2 mm, so as to enable the cross-sectional dimensions of the tip of the carrier 382 to be sized to pass through the working channel in a rapid exchange manner as described herein.

[0404] The alignment block can engage the optical fiber to hold the optical fiber. The curved engagement surface of the alignment block engages the optical fiber and holds the optical fiber in place. The lower engagement surface of the block also includes a substantially non-curved elongated channel portion proximal to the curved portion to engage the fiber and fix its location within the probe, for example, by holding the fiber between the block and the upper surface of the lower portion of carrier 382.

[0405] Fluid jets can be used at high pressures, such as for ablation, or at low pressures, such as for transmitting a columnar fluid jet or a light beam. Optical fibers can be bent, guided, and aligned by positioning the alignment block and alignment orifice to achieve the desired alignment. By positioning and securing the optical fiber in this manner, short, tight bend radii can be achieved. Cavitation and other fluid jet effects can be modified by varying the relative position and orientation of the jet alignment orifice.

[0406] The fluid stream emitted from the fluid delivery element may comprise a diverging stream 334 as shown in FIG. 23A or a columnar stream 333 as shown in FIG. 23B. The diverging stream 334 can be provided by providing a higher pressure to the delivery element. At higher pressures, for example, when the first fluid is a liquid and the second fluid is a liquid, the fluid jet will diverge. Alternatively, a lower pressure can be provided to provide the columnar stream 333 as shown. The columnar stream 333 can be provided when the emitted fluid is a liquid and the liquid is emitted into a gas, and the liquid can be emitted at a lower pressure in the range of 2 to 100 psi, for example, in the range of 5 to 25 psi. At lower pressures, the columnar fluid, including the columnar stream 333, can be used as a pointing device to point a laser beam for alignment. Alternatively, or in combination, the columnar fluid stream can be used to heat tissue, for example, for heating in conjunction with one or more of ablation, vaporization, or coagulation.

[0407] The diverging flow 334 can be provided by increasing pressure to the nozzle for tissue removal using the diverging flow, as described herein. The optical fiber of the carrier 382, ​​which may comprise the carrier tube 380, can be bent to provide a narrow profile configuration for the carrier 382. For example, the optical fiber can be bent with a radius within a range of approximately 1-10 mm, e.g., approximately 2-5 mm. This bending of the optical fiber can enable high efficiency emission and transmission of light energy from the light source to the desired tissue target. Additionally, the ends of the optical fiber can be aligned so that light emitted from the optical fiber is directed substantially through a channel defined by the nozzle that delivers the fluid flow. An alignment structure including an alignment orifice can be used to align the optical fiber with the jet orifice of the fluid delivery element.

[0408] FIG. 24 shows a carrier 382 including the fluid delivery element and design considerations of the fluid delivery element. The jet orifice design of the fluid delivery element can be configured in one or more of many ways. Varying the jet orifice geometry can change the fluid jet ablation characteristics. For example, cone angle variation will result in increased or decreased cavitation occurring at the nozzle exit. The jet orifice design may include a cone at one or more of the orifice's inlet or outlet. The cone angle can vary, for example, from 0 to 180 degrees. Varying the orifice diameter and orifice length can result in variations in nozzle backpressure and exit velocity of the fluid flow. The resulting entrainment zone changes with each of these parameters. The entrainment zone can include a cavitation bubble cloud generated by the nozzle. The depth of tissue penetration can be predicted and controlled based on the entrainment zone length. In many embodiments, the entrainment zone can be visualized using ultrasound or optical imaging, or a combination thereof. The entrainment zone corresponds to the region where cavitation occurs, which allows the entrainment zone to be visualized and may be referred to as the fluid flame zone. Cooling and cutting of the entrainment zone can enable tissue removal with minimal tissue damage. In many embodiments, the cone angle is in the range of about 40 degrees to about 80 degrees. The ratio of the orifice length to the orifice inner diameter can be in the range of about 1 to 10, for example, in the range of about 4 to 7. One skilled in the art can design a jet orifice to treat tissue as described herein based on the teachings provided herein.

[0409] 25A-25C illustrate jet deflection, according to an embodiment. A deflector 710 can be provided on the distal end of the carrier 382. Jet deflection can be achieved in one or more of a number of ways. The fluid jet can be deflected, for example, to achieve different cutting angles. Alternatively, or in combination, a deflected or redirected fluid jet can be utilized, for example, to clean the working channel and auxiliary devices. Fluid stream deflection can be manually or robotically actuated, for example, via pull wires, pneumatic pressure, hydraulics, mechanical linkages, and other means. The deflector can be movable under computer control, and the deflector may be gimbaled to change the deflection of the fluid stream relative to the longitudinal axis of the carrier 382. FIG. 25A illustrates deflection of the fluid stream to a first angle relative to the longitudinal axis, and FIG. 25B illustrates deflection of the fluid stream at a second angle relative to the longitudinal axis. FIG. 25C shows rotation of the fluid flow about the longitudinal axis with the fluid deflected at a second angle.

[0410] 26A-26C illustrate jet masking, according to an embodiment. Fluid jet masking can be used, for example, to achieve different cutting regions at a single location or multiple locations. The masking mechanism can be manually or robotically actuated, for example, via pull wires, pneumatic pressure, hydraulic pressure, mechanical linkages, and other means. In many embodiments, a hypotube extends along the carrier 382 to allow molding of the mask on the distal end of the carrier 382. The mask 720 includes a first configuration 722 as shown in FIG. 26A. As shown in FIG. 26B, the mask 720 includes a second configuration in which the mask is adjusted to provide a wider angle of the ejected fluid stream. FIG. 26C illustrates a third configuration 726 of the mask.

[0411] Mask embodiments as described herein can allow for rotation of the mask about the longitudinal axis for angles of rotation greater than 360 degrees. For example, multiple rotations can be used. Multiple mask configurations can enable sculpting of target tissue into a desired intended profile and can enable rapid removal of tissue at sweep rates that allow a smooth profile to be provided. The mask shape can enable bulk tissue removal with a large divergence angle for tissue proximal to the mask. For tissue more distant from the mask, the angle can be reduced to provide a reduced divergence of the jet to reach tissue at locations further from the mask.

[0412] 27A and 27B illustrate variations in jet angle, according to embodiments. The fluid jet angle and laser beam can be fixed at different angles to achieve cutting and coagulation. One or more of cutting or coagulation can be directed, for example, to a single location or multiple locations. Angling can help target tissue near an expandable anchor, such as a balloon, or reduce the risk of accidental contact with unintended tissue. The jet angle can be varied in one or more of a number of ways. For example, multiple carriers 730 can be provided, each of which may comprise carrier 382 having structures and components for treatment as described herein. Each of the multiple carriers 730 can provide a different fluid flow angle. For example, a first carrier can provide a first angle 732. A second carrier can provide a second jet along a second angle 734, and a third carrier can provide a third angle 736 as shown. The multiple probes may comprise a set of probes, e.g., three or more probes, each configured to direct one or more of the jet angle or the laser beam at an angle. For example, a first angle 732 can extend substantially perpendicular to the elongated axis, and a third angle 736 can be directed toward the distal end of the probe to ablate interior tissue, e.g., prostate tissue.

[0413] In many embodiments, multiple probes can be provided, with one or more jets exiting the device axially to target tissue directly distal to the device.

[0414] 28 illustrates multiple jets delivered simultaneously, according to an embodiment. The multiple jets of carrier 382 may comprise a primary jet 740 and a secondary jet 744 connected with a feed channel 742. Feed channel 742 may comprise a common feed channel.

[0415] Multiple jets can be employed to achieve simultaneous ablation and coagulation. This can be achieved through the use of a single delivery channel and multiple delivery channels. In the case of a single delivery channel, a small amount of pressure can be bled off to deliver a secondary jet. Additionally, a low-power laser pointer can be utilized for the secondary jet to aid in tissue targeting while the primary jet is used for ablation.

[0416] In many embodiments, the secondary jet can be used to direct the light beam to coagulate tissue, and the primary jet can be used to remove tissue while the secondary jet is utilized as a waveguide.

[0417] In many embodiments, the primary jet can be used to debride the tissue, while the secondary jet is used to coagulate the tissue.

[0418] FIG. 29 illustrates morcellation, according to an embodiment. In many embodiments, morcellation can be achieved simultaneously with resection using structural features, such as blades on the probe or spine. If integrated into the probe, morcellation can be automatically driven by probe movement. Vacuum suction can be used in conjunction with or independently of physical morcellation to increase collection flow. A combination of physical morcellation with an auger structure and vacuum can be utilized to regulate intraorgan pressure, for example.

[0419] The carrier 382 can extend to a distal end portion having one or more jets as described herein. Morcellation features can be provided proximally relative to the jets and may be contained within the working channel, for example, with an auger-shaped structure to remove tissue.

[0420] FIG. 30 illustrates a single-tube design, according to an embodiment. The single-tube design may include a fluid delivery element, such as an orifice jewel 762. The variable bend 760 allows the radius to bend, for example, when the carrier 382 is advanced within the working channel. A fluid is coupled to an orifice on the end of the carrier 382. The fluid may include a liquid or gas, and the orifice on the distal end can be configured in one or more of many ways, as described herein. FIGS. 31A and 31B illustrate a single-tube design, according to an embodiment. A fluid, such as a liquid or gas, can be used in conjunction with a laser, as described herein. The laser can emit electromagnetic energy that is transmitted along an energy conduit 351, such as an optical fiber, as described herein. The variable bend 760 can be provided near a fluid delivery element, such as an orifice jewel 762 on the distal end. The optical fiber can be aligned with a structure as shown in FIG. 31B. For example, a fiber guide can be used to locate the optical fiber coaxially with the orifice of the fluid jet.

[0421] The single-tube design according to the embodiments of Figures 30, 31A, and 31B can offer many advantages. For example, package size and complexity can be significantly reduced when utilizing a single-tube design. For example, internal laminar flow characteristics can be improved using a single-tube design because the fluid path can be more continuous than with other designs. The orifice jewel can be swaged in place, or a small cover can be laser welded to hold the jewel. Fiber optic integration can be achieved through the use of internal fiber alignment structures. The bend angle and radius can be varied to allow for alternative tissue targeting or manufacturing. Multiple jets can be employed to balance the jet reaction process and cut more than one location simultaneously. For example, opposing jets can be used. Additional jets can be added, for example, to power the rotational motion of the catheter.

[0422] The small package size can allow implementation in the form of a small catheter, which can enable use with commercially available rigid and flexible introducers and endoscopes of the prior art. The distal tip shape can be pre-formed with a given bend angle to access tissue volumes.

[0423] 32 illustrates a means for aligning and locating a treatment system with respect to human anatomy, according to an embodiment. The plurality of expandable anchors 770 includes a first expandable anchor 772 and a second expandable anchor 774. The first expandable anchor 772 may comprise, for example, a balloon, and the second expandable anchor 774 may comprise, for example, a second balloon. The first expandable structure can be configured to expand within the bladder neck, and the second expandable structure can be configured to expand within the urethra to contain movement of the device.

[0424] 33 shows multiple expandable structures including a first expandable basket 776 and a second expandable basket 778. The expandable baskets can be permeable or impermeable and can expand to allow anchoring. An impermeable basket can block fluid flow through the urethra, while a permeable expandable basket can allow fluid flow through the urethra between the urethra and the bladder.

[0425] The multiple expandable structures can have the benefit of limiting movement of the probe both from the bladder towards the urethra and from the urethra towards the bladder neck so as to effectively lock the anchor in place.

[0426] 34 illustrates a means for aligning the system with respect to the human anatomy. For example, the plurality of expandable anchors 770 may comprise a first expandable anchor 777 and a second expandable anchor 779. The first expandable anchor 777 may comprise, for example, a balloon or basket. The expandable anchor 777 is used to position against the posterior wall of the bladder. The second expandable anchor is positioned within the bladder neck. The first and second expandable anchors can lock the position of the probe to prevent migration. A counter force can be applied manually or via robotic control.

[0427] In some embodiments, opposing forces can be applied between the first and second expandable anchors to push the first expandable anchor toward the bladder wall and the second expandable anchor toward the bladder neck.

[0428] Additional anchoring embodiments can be provided in accordance with the teachings described herein. For example, suction means can be used for anchoring. Alternatively, sensors for patient movement can be used. Arms can be used for anchoring. A clamp can be provided on the groin for anchoring. Magnetic forces can be used to hold the system in place. Suction can be used to provide attachment to tissue. Each of these provides non-limiting examples of anchoring means in accordance with embodiments described herein.

[0429] FIG. 35 shows a disposable balloon, according to an embodiment. The disposable balloon 780 can be threaded onto the distal end of a carrier 382. The disposable balloon may include female threads at the tip of the balloon. The female threads 782 can engage with male threads 784. The threaded engagement between the balloon and the carrier can allow the balloon to be removed after treatment, and the carrier 382 can be sterilized. An inflation hole can be provided. The inflation hole 786 allows inflation of the balloon 780 when the balloon 780 is threadedly engaged onto the distal tip. The disposable balloon can be individually sterilized. Threaded attachment of the balloon can be provided to a handpiece or to the carrier, as described herein. Sealing can be achieved using an O-ring and threaded engagement. A balloon capable of achieving a 1:7 fold-to-inflate ratio can be provided.

[0430] FIG. 36 illustrates tissue ablation and depth control according to an embodiment. A live patient ultrasound image is shown. FIG. 37 illustrates a visible fluid flame in saline. The visible fluid flame in saline corresponds to the entrainment region of the jet as described herein. The visibility of the entrainment region fluid flame is provided by the cavitation of small gas bubbles, which may generate optical or acoustic scattering to make the entrainment region fluid flame visible, for example, with ultrasound or optical imaging. The benefit of the visible entrainment region can be for the physician to visualize the treatment distance and compare this distance with ultrasound. FIG. 37 illustrates a visible entrainment region at 11 millimeters, the same size as shown in FIG. 36. The substantial similarity in the entrainment region distance corresponds to the tissue ablation and removal distance. This experimental result, showing the visualization of the entrainment region, can provide a safer treatment. By way of example only, flow parameters used with the images shown in FIGS. 36 and 37 include a flow rate of approximately 130 millimeters per minute and a nozzle back pressure of approximately 2700 psi. The nozzle arrangement on the carrier includes a first liquid that is emitted with a diverging flow as described herein into a second fluid to provide a diverging flow, the second fluid including a liquid.

[0431] When treating a patient, a physician can use live patient ultrasound, such as transrectal ultrasound (hereafter "TRUS") as described herein. The physician can perform an ultrasound examination from the probe tip into the entrainment region. This can be used to determine appropriate parameters to treat the patient. For example, the physician can adjust the pressure to limit the depth of penetration of the probe tip so that the probe tip does not emit energy beyond the organ capsule, such as the prostate capsule, causing external ablation of the organ. The image in FIG. 36 shows a structure corresponding to the expandable balloon on the left side of the image, with the arrow indicating the 11-millimeter dimension. FIG. 37 is an optical image showing a similar distance in the entrainment region. The sweeping motion of the flow shown in FIG. 36 can be used to adjust the treatment contained within the prostate.

[0432] Figure 38 illustrates tissue ablation depth control, according to an embodiment. Live patient ultrasound from a patient similar to Figure 37, but with increased backflow pressure to the nozzle, is shown in Figure 38.

[0433] FIG. 39 shows optical images of a fluid flame in saline, showing the entrainment region with different pressures. The pressure flow parameters in FIGS. 38 and 39 include an approximate flow rate of 205 millimeters per minute and a nozzle back pressure of approximately 5760 psi. The corresponding tissue ablation depth is approximately 16 millimeters. A live patient ultrasound image shows a 16 millimeter entrainment region similar to the entrainment region seen optically. The sweeping motion of the probe and the fluid flow emitted from the probe, as seen on the left side of the image, can be used to set flow parameters and pressures to safely treat the patient using ultrasound images of the entrainment region.

[0434] FIG. 40 shows nozzle flow rates versus maximum penetration depths for multiple pressures and nozzles. Flow rates in millimeters per minute are shown. Maximum penetration depths are also shown as a function of flow rate. The 130-micron nozzle is indicated by a diamond, and the 150-micron nozzle is indicated by an X. Tissue penetration depths can be used based on the teachings described herein to set treatment flow rate parameters. For example, for treatment up to the maximum penetration depth of a 12- or 130-millimeter nozzle, a flow rate of 150 millimeters per minute is selected. Similarly, for a 150-micron nozzle, a flow rate of 200 millimeters per minute is selected. One skilled in the art can develop software to automatically identify a nozzle for treatment based on depth and to identify a suitable flow rate for treatment based on depth. Additionally, flow rates can be varied based on tissue profiles, such as those described herein. For example, tissue treatment profiles based on axial and sagittal images, such as those described herein.

[0435] Figure 41 shows nozzle backpressure versus maximum penetration depth. Maximum penetration in millimeters is shown as a function of nozzle pressure in psi for both a 130 micron nozzle and a 150 micron nozzle. Based on the identified nozzle size and tissue penetration depth, the software or user can identify the appropriate nozzle pressure to treat the patient.

[0436] FIG. 42 shows nozzle flow rate versus back pressure for a 130-micron nozzle and a 150-micron nozzle. Pressure and flow rate are shown. For flow rate, flow rate is shown in millimeters per minute and pressure in psi. Flow rate can be from about 100 millimeters per minute to about 250 millimeters per minute, and pressure can be from less than 1000 psi to as high as 4000 psi, or, for example, 8000 psi. In specific embodiments, flow rate with larger diameter nozzles is approximately linear with pressure, and flow rate with a 130-micron nozzle is approximately linear with pressure. These relationships between flow rate and pressure can be used to appropriately set treatment pressure for a desired flow rate. Furthermore, these flow rate-pressure relationships can be nonlinear as the range is extended to lower values, or higher values, or both. Alternatively, or in addition, flow rate-pressure relationships can be nonlinear, for example, when different nozzles with different characteristics are used.

[0437] One skilled in the art can use one or more of nozzle pressure, cutting depth, and flow rate to ablate tissue to a predetermined profile and volume, as described herein.

[0438] While preferred embodiments of the present disclosure have been shown and described herein, it will be apparent to those skilled in the art that such embodiments are provided by way of example only. Numerous variations, changes, and substitutions will be apparent to those skilled in the art without departing from the scope of the present disclosure. It is understood that various alternatives to the embodiments of the present disclosure described herein may be employed without departing from the scope of the invention. Accordingly, the scope of the present invention is to be defined solely by the appended claims and their equivalents.

Claims

1. An apparatus for treating the prostate tissue of a patient, wherein the apparatus is: An arm configured to be coupled to a therapeutic probe equipped with an energy source, the arm being configured to support the therapeutic probe when the therapeutic probe is inserted into the patient's urethra, One or more processors, To provide multiple images of the prostate on the display, The system receives user input to define a treatment profile on each of the aforementioned multiple images, To indicate the treatment angle of the energy source, a rotation marker is displayed in one or more of the multiple images. One or more processors configured to perform the following: A device equipped with the following features.

2. The apparatus according to claim 1, wherein the plurality of images comprises a plurality of axial images, and the treatment profile is superimposed on each of the plurality of axial images.

3. The apparatus according to claim 1, wherein one or more processors are configured to be operablely coupled to the therapeutic probe, and the angle of the rotation marker corresponds to the angle of rotation of the energy source around the longitudinal axis of the therapeutic probe.

4. The apparatus according to claim 3, wherein one or more processors are configured to display the rotation marker on each of the plurality of images.

5. The apparatus according to claim 3, wherein the rotating marker shown on the display comprises a line configured to rotate around a location on the display, the location on the display corresponding to the longitudinal axis of the treatment probe.

6. The apparatus according to claim 5, wherein the angle of rotation of the rotating marker shown on the display corresponds to the angle of rotation of the energy source around the longitudinal axis.

7. The apparatus according to claim 6, wherein the angle of rotation of the rotating marker corresponds to the angle of energy delivered from the energy source through the patient's urethra.

8. The apparatus according to claim 5, wherein the line comprises a colored line.

9. The apparatus according to claim 8, wherein the colored line comprises a green line.

10. The apparatus according to claim 1, wherein the user input is configured to define the radial distance from the longitudinal axis of the treatment probe to the outer boundary of the treatment profile on each of the plurality of images.

11. The apparatus according to claim 10, wherein the radial distance from the longitudinal axis to the outer boundary varies with the angle of rotation around the longitudinal axis.

12. The apparatus according to claim 11, wherein one or more processors are configured to rotate the treatment probe so as to rotate the energy source around the longitudinal axis.

13. The apparatus according to claim 1, wherein the treatment profile includes a boundary line corresponding to the boundary between the cauterized tissue and the uncauterized tissue.

14. The apparatus according to claim 1, wherein the plurality of images include magnetic resonance imaging (MRI) data.

15. The apparatus according to claim 1, wherein the energy source is configured to heat the tissue.

16. The apparatus according to claim 1, further comprising: a patient support configured to position a patient in the lithotomy position; and a chain section configured to rotate the treatment probe while the patient is in the lithotomy position and the arm is supporting the treatment probe inserted into the prostate.

Images