Focal therapy is an emerging, minimally invasive treatment option for localized prostate cancer, specifically designed to treat only the cancerous area of the prostate while preserving the surrounding healthy tissue and critical structures responsible for urinary continence and erectile function. This helps lower the risk of side effects, especially those related to urinary control and sexual function.

Focal therapy is generally recommended for selected patients, particularly those with localized prostate cancer, where the tumor is confined to one part of the prostate.

In some cases, focal therapy is also used as a salvage treatment for patients experiencing local recurrence of cancer after undergoing external beam radiotherapy.

The procedure involves using real-time imaging techniques to guide precise application of an energy source—such as heat (e.g., high-intensity focused ultrasound – HIFU), cold (cryoablation), or electric pulses (irreversible electroporation)—to destroy cancerous tissue. This targeted approach provides several potential advantages over more traditional treatments:

• It limits the destruction of healthy prostate tissue.
• It often results in fewer and less severe side effects, particularly regarding urinary and sexual functions.
• It is usually performed on an outpatient basis, allowing for quicker recovery.

Overall, the goal of focal therapy is to effectively treat the cancer while minimizing the risks and complications associated with more aggressive treatments. While long-term outcomes are still under investigation, current evidence supports its safety and effectiveness for a carefully selected group of patients.

The Benefits of Focal Therapy

Focal therapy is a less invasive treatment for localized prostate cancer that targets only the tumor, unlike traditional treatments like surgery or radiation that treat the whole prostate and often cause side effects such as erectile dysfunction, urinary incontinence, and bowel problems. Focal therapy helps preserve healthy tissue and reduces the risk of side effects. As a result, it is less likely to cause erectile dysfunction, urinary incontinence, and bowel problems. 

Side Effects of Radical Prostatectomy and Radiotherapy

Most men diagnosed with localized prostate cancer (meaning the cancer has not spread outside the prostate) are typically offered whole-gland treatments, such as radical radiotherapy or prostatectomy (surgical removal of the prostate). These treatments are very effective and are known to improve cancer control and survival in the long term but that cancer control and survival in the long term in the majority of cases is a small benefit over monitoring the cancer.

However, treating the entire prostate with surgery or radiotherapy can also affect nearby healthy tissues. For example, nerves and structures responsible for erections (neurovascular bundles), as well as muscles and nerves that control urination, may be damaged. The urethra, the tube that carries urine through the prostate, can also be affected—causing symptoms like frequent urination, urgency, or discomfort. The bladder, which is located very close to the prostate, can also be irritated during treatment, leading to similar urinary symptoms. With radiation especially, the rectum (back passage)—located just millimeters behind the prostate—may be exposed to radiation and develop side effects such as discomfort, bleeding, or loose stools.

Side Effects After Radical Prostatectomy:

After prostate removal surgery, urinary incontinence (requiring at least one pad per day) affects about 15% to 25% of men long-term, with around 5% to 10% needing more than one pad per day. These rates are usually higher in the first 6 to 12 months after surgery.
Erectile dysfunction occurs in approximately 30% to 60% of men, depending on how well the nerves were preserved during surgery. All patients will lose the ability to ejaculate, and even those who regain erections may need assistance through medication, injections, or vacuum devices.
Additionally, around 5% of patients develop a narrowing (stricture) at the connection point between the bladder and urethra (the anastomosis site), which can affect urination.

Side Effects After Radiotherapy:

With radiotherapy, long-term urinary incontinence (like leaking when coughing, sneezing, or lifting) is less common—affecting less than 5% of patients. However, other urinary issues like urgency, frequent urination, nighttime urination, or discomfort while urinating may occur due to irritation of the bladder and urethra. Some patients will need pads because of urge incontinence (inability to hold urine during sudden urges).
Erectile dysfunction also affects around 50% of men in the long term, and ejaculation is usually lost. Outcomes depend on sexual function before treatment.
Radiotherapy may also cause bowel symptoms: about 5% of men develop serious symptoms like bleeding or diarrhea, while another 5% to 10% experience milder bowel issues.

Brachytherapy and Other Forms of Radiotherapy:

Brachytherapy (placing radioactive seeds directly into the prostate) carries different types and levels of urinary, sexual, and bowel side effects compared to external beam radiotherapy.
Currently, there is no strong evidence that newer techniques like stereotactic radiotherapy or proton therapy significantly reduce side effects or improve outcomes, although they may require fewer treatment sessions.

Focal therapy is therefore an alternative in those patients that are eligible, instead of whole-gland radical surgery or radiotherapy.

Who’s eligible for focal therapy?

People with intermediate-risk prostate cancer are the best candidates for focal therapy. Low-risk cancers are better managed with active surveillance and high-risk cancers are better treated with whole-gland therapies (like surgery or radiation).

Ideal Candidates for Focal Therapy;

Focal therapy is most effective for prostate cancer patients who meet specific criteria. The ideal candidates generally have low- to intermediate-risk disease, confined to a limited area within the prostate. Several factors determine eligibility:

1. Low-Risk and Intermediate-Risk Prostate Cancer

• Patients with a Gleason score of 6 or 7, with grade group 1 to 3 cancers (which indicates less aggressive cancer) are the best candidates.
• Those with high-risk or more aggressive cancers (Gleason score 8-10, with grade group 4 or 5 cancers) are not suitable, as their cancer is more likely to recur or spread.

2. Tumors Confined to the Prostate

• The effectiveness of focal therapy depends on whether the cancer is restricted to one or a few distinct areas within the prostate.
• Advanced imaging techniques such as multiparametric MRI (mpMRI) and targeted prostate biopsies help identify the exact cancer location and size.

3. PSA Levels Below a Certain Threshold

• Candidates typically have a prostate-specific antigen (PSA) level of 20 ng/mL or lower.
• Higher PSA levels may indicate a more aggressive or widespread disease, making focal therapy less effective.

4. No Evidence of Metastasis

• Focal therapy is only suitable for patients whose cancer is localized and has not spread to lymph nodes, bones, or other distant areas.
• Whole-body imaging may be required to confirm that there are no signs of metastasis.

5. Previous Prostate Radiotherapy but Cancer Recurs

• Men who have cancer recurring after undergoing previous radiation therapy can have successful focal therapy.
• Recurrent prostate cancer must be confined within the prostate gland to be suitable for focal therapy

6. Patients Seeking a Less Invasive Treatment

• Men who prefer to avoid the potential side effects of surgery or whole-gland prostate radiation may find focal therapy a more attractive option.
• However, men need to understand and accept the possibility of additional treatments in the future.

Who May Not Be a Good Candidate?;

While focal therapy offers a promising treatment approach, it is not suitable for all prostate cancer patients. Certain conditions and cancer characteristics can make this approach ineffective or inappropriate.

1. High-Risk or Aggressive Tumors

• Patients with Gleason scores of 8-10, with grade group 4 or 5 cancers, typically have more aggressive cancers that are more likely to recur.
• These patients require more comprehensive treatment options, such as radical prostatectomy with bilateral pelvic lymph node surgery, or whole-gland radiation therapy in addition to hormone therapy.

2. Widespread Cancer in Multiple Extensive Areas of the Prostate

• If cancer is spread outside the capsule of the prostate, focal therapy may leave untreated areas, leading to recurrence.
• More aggressive approach may be recommended for multifocal or bilateral tumours based on the cancer location.

3. Very High PSA Levels

• Patients with PSA levels significantly above 20 ng/mL are more likely to have extensive disease that cannot be effectively treated with focal therapy alone.
• Additional diagnostic tests, such as bone scans or PET-CT scans, may be needed to determine if the cancer has spread.

4. Men Who Want a Single Definitive Treatment

• Some patients prefer a one-time treatment option that eliminates cancer with minimal risk of recurrence, and also accept the potential side effects of traditional treatment.
• Focal therapy for prostate cancer may require additional procedures if cancer returns, in order to have less side effects, less urine incontinence, or less erectile dysfunction.

What types of focal therapy are there for prostate cancer?

Types of focal therapy include:

🔹 1. High-Intensity Focused Ultrasound (HIFU)

• Uses focused sound waves to heat and destroy cancer cells.
• One of the most widely used focal therapy methods.

🔹 2. Cryotherapy (Cryoablation)

• Freezes prostate tissue to kill cancer cells using cold gases like argon or helium.

🔹 3. Irreversible Electroporation (IRE / NanoKnife)

• Uses short electrical pulses to create pores in cell membranes, leading to cancer cell death without significant heating or freezing.
• Especially useful near sensitive structures (like nerves).

🔹 4. Laser Ablation (FLA)

• Delivers focused laser energy to heat and destroy cancerous tissue.
• Often guided by MRI.

🔹 5. Photodynamic Therapy (PDT)

• Uses light-sensitive drugs activated by laser light to kill cancer cells.
• Less commonly used, but still an option in certain settings.

🔹 6. Radiofrequency Ablation (RFA) (less common)

• Uses electrical current to produce heat and destroy cancer tissue.

🔹 7. Microwave Ablation (MWA) (experimental/limited use)

• Similar to RFA, but uses microwave energy for tissue heating.

8. Transurethral ultrasound ablation of the prostate (TULSA): Heat from sound waves destroys tumor cells.

Which Energy Source is Best for Focal Therapy?

There is no single energy source that is ideal for all patients. The most suitable energy source for each patient varies depending on several factors, including the location of the lesion, its relationship with surrounding anatomical structures, the size of the lesion, and the patient’s individual anatomy. Each energy source has its own patient-specific advantages and disadvantages. It should be taken into consideration that operators with experience in multiple energy sources are more likely to offer the most suitable option for the patient based on their expertise.

Is the Operator’s Experience Important in the Success of Focal Therapy?

Yes, the success of focal therapy depends greatly on the experience of the doctor (operator) performing the procedure.

Focal therapy requires precise targeting of the tumor using advanced imaging and energy-based treatment techniques. An experienced operator is better at:

• Choosing the right energy source based on the patient’s anatomy and tumor location,
• Applying the treatment accurately,
• Reducing the risk of damage to healthy tissue.

Studies have shown that higher operator experience is linked to better treatment outcomes, including higher success rates and fewer side effects such as urinary or sexual problems. In contrast, less experienced operators may have lower success rates and more complications.

That’s why it’s important to choose a center or physician with strong experience in focal therapy techniques.

After Focal Therapy Treatment

Most people don’t feel pain or discomfort after the treatment. However, some mild symptoms can happen, like soreness, burning, and/or light bruising.  It is normal to see small amounts of blood in your urine for several weeks after the procedure. Your prostate may swell, which can make urination difficult. A temporary catheter can be placed in your urethra. This tube is usually removed within a few days during a follow-up visit.

You’ll have regular follow-up appointments to monitor your healing. These may include blood tests (PSA levels every six months), annual MRI scans, and sometimes a prostate biopsy if there is suspicion of recurrence.