Focal therapy for prostate cancer: Challenges with patient selection, treatment modalities, and follow-up

Prostate cancer (PCa) remains the most common malignancy among men. Historically, the standard treatments for localized, clinically significant PCa have been radical prostatectomy or radiation therapy. However, the need to achieve optimal oncological outcomes while maintaining quality of life has led to the development of focal therapy (FT) as a novel treatment modality. At present, FT is performed using different types of energy sources: (i) cryotherapy, (ii) irreversible electroporation, (iii) high-intensity focused ultrasound, (iv) transurethral ultrasound ablation, (v) focal laser therapy, (vi) bipolar radiofrequency ablation, and (vii) photodynamic therapy. The role of FT in PCa is highly debated for several reasons, mainly because the disease is multifocal in most cases, and long-term outcomes from prospective clinical trials are still lacking. Nevertheless, it has been suggested that focal treatment of the index lesion is sufficient, as this lesion is believed to drive metastatic spread. Therefore, FT is considered a potential treatment option for patients with organ-confined, intermediate-risk PCa as an alternative to whole-gland treatments. Although FT generally preserves voiding and sexual functions, its effectiveness in cancer control needs to be validated through high-quality comparative trials. The aim of this article is to discuss the challenges of patient selection and review the various FT modalities and follow-up strategies after treatment.