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Review

SIU-ICUD Focal Therapy for PCa: The Technique

by
Lara Rodriguez-Sanchez
1,*,
Thomas J. Polascik
2,
Kara Watts
3,
Peter Ka-Fung Chiu
4,
Mark Emberton
5,
Behfar Ehdaie
6,
Hashim U. Ahmed
7,
Andre Abreu
8,
Ardeshir R. Rastinehad
9 and
Rafael Sanchez-Salas
10
1
Department of Urology, Institut Mutualiste Montsouris, 75014 Paris, France
2
Department of Urology, Duke Cancer Institute, Durham, NC 27710, USA
3
Department of Urology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467, USA
4
SH Ho Urology Centre, Department of Surgery, The Chinese University of Hong Kong, Hong Kong 9990777, China
5
Division of Surgery and Interventional Science, University College London, London WC1E 6BT, UK
6
Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
7
Imperial Prostate, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London W6 8RF, UK
8
Keck Medical Center of USC, USC Institute of Urology, University of Southern California, Los Angeles, CA 90033, USA
9
Northwell Health, Smith Institute for Urology at Lenox Hill Hospital, Lake Success, NY 11042, USA
10
Division of Urology, Department of Surgery, McGill University, Montreal, QC H3A 0G4, Canada
*
Author to whom correspondence should be addressed.
Soc. Int. Urol. J. 2025, 6(3), 38; https://doi.org/10.3390/siuj6030038 (registering DOI)
Submission received: 3 December 2024 / Revised: 25 February 2025 / Accepted: 25 March 2025 / Published: 7 June 2025
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Versions Notes

Abstract

:
Background/Objectives: Focal therapy (FT) and technology are closely connected. Advanced imaging allows for precise identification of the index lesion, enabling the targeted use of various thermal and non-thermal energy sources through different approaches, with specific techniques tailored to lesion location and operator expertise. This personalized approach enhances both safety and effectiveness, facilitating customized treatment planning. Methods: The International Consultation on Urological Diseases formed a committee to review the current literature on FT for prostate cancer (PCa), focusing specifically on the technique. Following in-depth discussions, the committee chose a “by lesion” approach rather than the traditional “by energy” approach to structure the review. A comprehensive PubMed search was conducted to gather relevant articles on the various energy modalities and procedural approaches used in FT for PCa. Results: Lesions in the apex, anterior, and posterior regions of the prostate can be accessed through several FT approaches, each associated with specific energy modalities and techniques. The transrectal approach utilizes high-intensity focused ultrasound (HIFU) and focal laser ablation (FLA), while the transperineal approach is compatible with energy sources such as cryotherapy, irreversible electroporation (IRE), brachytherapy, and FLA. The transurethral approach supports methods such as transurethral ultrasound ablation (TULSA). Each approach offers distinct advantages based on lesion location, treatment area, and energy modality. The choice of technique evaluated the safety and efficacy of each energy source and approach based on specific treatment areas within the prostate, highlighting the need for robust research across lesion locations and modalities, rather than focusing solely on each modality for a specific region. Conclusions: FT is rapidly advancing with new energy sources, technological improvements, and increasing operator expertise. To further optimize FT, research should prioritize evaluating the safety and effectiveness of different energy sources for various lesion locations, focusing on the treatment area rather than the energy modality itself.

1. Introduction

Although long-term oncological outcomes and the non-inferiority of focal therapy (FT) compared to standard treatments (radiotherapy or radical prostatectomy) are still lacking, its proven superior functional outcomes compared to these radical treatments highlight the need for continued research and advancement in this field [1].
FT marks a paradigm shift in prostate cancer (PCa) management, drawing parallels with the targeted/subtotal approaches used in other solid organ cancers, like kidney cancer [2,3]. It relies on advanced technologies, such as magnetic resonance imaging (MRI), for precise lesion localization and targeted biopsies [4]. Additionally, emerging imaging modalities, including micro-ultrasound and prostate-specific membrane antigen positron emission tomography (PSMA-PET), combined with artificial intelligence (AI), promise to further enhance diagnostic accuracy and staging [5,6,7]. As technology evolves, so does FT, influencing patient selection, treatment planning, and delivery. This approach includes selecting the most appropriate energy sources, optimizing energy delivery parameters, utilizing advanced monitoring systems, and even exploring systemic treatments to enhance oncological outcomes, with the aim of achieving optimal efficacy while minimizing the side effects typically associated with whole-gland therapies.
In response, the International Consultation on Urological Diseases (ICUD) convened a committee to review the literature on FT for PCa, focusing on procedural techniques.
Drawing from the ICUD chapter on FT techniques, this review aims to assess the current state of FT by providing a comprehensive analysis of the most commonly utilized energy sources, their mechanisms of action, and their clinical applications. Moreover, the review adopts a “by lesion” framework—departing from the traditional “by energy” approach—to guide its evaluation.

2. Materials and Methods

A comprehensive PubMed search was conducted using the keywords “prostate cancer” and “focal therapy” to gather relevant literature. Retrospective and prospective studies, along with reviews on PCa and FT, with a particular focus on energy sources and/or lesion location analysis, especially those presenting the latest outcomes and systematic reviews published in English, were included in this non-systematic literature review. The search informed the in-depth chapter included in the 3rd World Urologic Oncology Federation (WUOF)/Société Internationale d’Urologie (SIU) ICUD on localized PCa [8].
To ensure that the review remained up to date, an additional literature search was performed in February 2025, identifying new relevant studies, leading to the inclusion of an additional study.
Given the nature of this study—a narrative review of the existing literature—consultation with an ethics committee was not required.

3. Focal Therapy Techniques and Strategies Applicable to Every Energy Source

3.1. Treatment Approach

3.1.1. Accessing the Lesion for Targeted Focal Therapy

Accurate biopsy and precise disease localization are crucial for effective FT. Biopsy accuracy ensures reliable diagnosis and guides treatment planning, while precise localization minimizes complications and enables tailored therapeutic strategies.
Three main approaches for accessing the prostate are available (Figure 1):
  • Transrectal approach: Access through the rectal wall, suitable for techniques like high-intensity focused ultrasound (HIFU) and focal laser ablation (FLA).
  • Transperineal approach: Access through the perineum, enabling the use of cryotherapy, irreversible electroporation (IRE), and FLA.
  • Transurethral approach: Access through the urethra, employed in transurethral ultrasound ablation (TULSA) and water vapor-based treatments.
In 2016, the “à la carte” method was introduced to tailor FT for PCa based on lesion location, recommending transperineal needle-driven energies for anterior lesions, rectal access techniques for posterior lesions, and brachytherapy for apical lesions due to its non-thermal benefits [9].
Since then, advancements and experience have refined this approach. Transurethral devices like TULSA enable uniform circumferential access, while novel new non-thermal energies such as IRE have proven effective for treating posterior and apical lesions. Additionally, cryotherapy has recently been suggested to yield favorable functional and oncological outcomes not only for anteriorly located lesions but also for posterior ones [10,11,12].
While the “à la carte” method remains a valuable planning tool, particularly for those in the learning phase, operator expertise and the ability to access lesions seem to be the true foundations of successful FT for PCa [13].

3.1.2. Treatment Planning—Zone of Ablation

FT has evolved from large ablations, such as hemi-gland ablation, to a more precise approach targeting specific lesions with a rim of normal parenchyma. Challenges such as MRI underestimating lesion size and biopsy sampling errors have prompted a balanced strategy between large and ultra-focal treatments [14].
Research highlights the critical role of treatment margins. Le Nobin et al. recommend a 9 mm margin due to MRI’s tendency to underestimate tumor size, while Aslim et al. found a 5–6 mm margin sufficient for tumors up to 12 mm [14,15]. Brisbane et al. introduced the concept of a “penumbra,” a halo of clinically significant cancer around MRI-visible lesions, emphasizing the need to address this area for FT success [16]. On the other hand, evidence, including studies on IRE, shows no added benefit of extended ablations over focal treatments with proper margins [17].
In conclusion, both extended and ultra-focal approaches should be avoided. A minimum 5 mm margin is crucial for effective FT, with a 10 mm margin warranted for larger or aggressive lesions, as supported by the Focal Therapy Consensus (FALCON) [13].

3.1.3. Intraoperative Monitoring and Strategy

Intraoperative monitoring aims to improve treatment accuracy, reduce in-field failures, and minimize side effects in FT.
Ehdaie et al. explored MR-guided focused ultrasound (MRgFUS) in a phase 2b multicenter study. This system integrates transrectal ultrasound for energy delivery with MRI to visualize the tumor, provide real-time feedback via MRI thermometry, and assess tissue post-treatment. The study showed higher success rates in treating targeted regions compared to previous HIFU trials, but further comparative studies are needed [18].
Contrast-enhanced ultrasound (CEUS) is another promising tool for guiding intraoperative HIFU. Bacchetta et al. demonstrated CEUS’s ability to identify undertreated areas, enabling additional ablation, with post-treatment CEUS correlating well with early MRI results. However, more studies are required to confirm its efficacy in enhancing focal HIFU outcomes [19].

3.1.4. How Much Energy Is Enough?

Optimal dose delivery in FT may involve repeating procedures in the same session, as in cryotherapy, or enhancing overlapping ablative areas, as seen in HIFU. Cryotherapy typically employs two freeze–thaw cycles, while Huber et al. demonstrated improved outcomes with three overlapping HIFU blocks compared to the standard two, reducing in-field recurrence from 31% to 19% (Figure 2).
The double-tap HIFU strategy, which involves delivering HIFU twice in the same session for additional treatment boosts, remains debated. While some studies suggest that it may reduce in-field recurrence, no conclusive evidence has demonstrated improved oncological outcomes with this approach [20].

3.1.5. Systemic Treatments

The justification for the observed improvement in overall survival by adding androgen deprivation therapy (ADT) to radiotherapy (RT) for intermediate- and high-risk PCa remains unclear, with proposed mechanisms including vascular endothelial growth factor 1 (VEGF1) suppression, immune modulation, and androgen receptor regulation with DNA repair inhibition [21,22,23].
In FT, some of these mechanisms may also explain the potential benefits of combining FT with ADT. Trials like Comparative Healthcare Research Outcomes of Novel Surgery in prostate cancer (CHRONOS)-B are comparing FT alone to FT with neoadjuvant medication, while the EvaluatioN of HIFU Hemiablation and short-term AndrogeN deprivation therapy Combination to Enhance prostate cancer control (ENHANCE) trial is assessing the impact of pre-treatment ADT. Nevertheless, systemic therapy is not yet recommended as a routine adjunct to FT, pending further evidence [24,25].

3.1.6. Integrating Focal Therapy with Prostate Radiotherapy

Preliminary research highlights a novel approach in FT for PCa, combining FT with external RT, akin to breast cancer treatment, where lumpectomy is complemented by RT.
The Focal Lesion Ablative Microboost in Prostate Cancer (FLAME) trial randomized 571 patients with intermediate- and high-risk PCa to standard RT (77 Gy) or the same treatment with an additional 95 Gy focal boost to the mMRI-visible lesion. After 72 months, the focal boost arm improved biochemical disease-free (BCR) survival (92% vs. 85%) without significantly affecting toxicity or quality of life [26].
Similarly, the Radiation Therapy and IRreversible Electroporation for Intermediate Risk Prostate Cancer (RTIRE) study is investigating IRE followed by stereotactic body RT (32.5 Gy) for International Society of Urological Pathology (ISUP) 2 and 3 PCa. Results from the RTIRE trial are awaited [27].

3.2. Energies

A comparison of the main energy-based prostate treatments is presented in Table 1, with further explanations provided afterward.

3.2.1. HIFU and MRI-Guided TULSA

HIFU therapy uses focused ultrasound waves to generate heat (60–90 °C), causing coagulative necrosis and cavitation, where microbubbles form, expand, and collapse, creating mechanical forces that destroy the targeted tissue [28]. The procedure, performed under general (generally preferred for immobility) or spinal anesthesia, is typically outpatient. Rectal preparation is essential, as is ruling out intraprostatic calcifications. Lesions must be within 3–4 cm of the probe for effective treatment, which lasts 1–3 h. Patients require a urinary catheter for at least 48 h post-procedure to mitigate urinary retention risk [1].
TULSA is a novel alternative to traditional transrectal HIFU, utilizing a transurethral probe guided by real-time MRI. It ensures precision with MRI thermometry and employs cooling devices to protect the urethra and rectal wall. Patient movement triggers an automatic system shutdown for recalibration, requiring general anesthesia and sometimes intraoperative glucagon to minimize rectal motion.
Key differences between TULSA and HIFU include the following:
  • TULSA delivers energy from the urethra, while HIFU uses a rectal probe.
  • TULSA relies on MRI guidance, whereas HIFU uses transrectal ultrasound.
  • TULSA creates a single energy plane, while HIFU forms multiple focused beams.
TULSA is unsuitable for patients with non-MRI-compatible implants, pelvic metal hardware, or lesion margins over 3 cm from the urethra. Patients with calcifications, cysts, or urethral strictures also require careful evaluation [11].

3.2.2. Cryotherapy

Cryotherapy ablates tissue through two standard freeze–thaw cycles, delivering freezing temperatures below −40 °C. This forms ice balls that cause intracellular dehydration, membrane disruption, and cell death. Immediate damage is followed by delayed vascular injury, where freezing induces vasoconstriction and hypoxia, and thawing leads to endothelial damage, edema, platelet aggregation, and microthrombi formation, progressively reducing vascularization [27].
Like HIFU, cryotherapy is typically performed as an outpatient procedure under spinal, general, or local anesthesia, with some reports of office-based treatments [29]. A transurethral warming device protects the urethra, while cryoneedles, guided by transrectal ultrasound, are inserted transperineally. Temperature probes may be used to monitor key areas throughout the procedure. Following treatment, a catheter is placed for at least 48 h to mitigate the risk of post-treatment urinary retention [30].

3.2.3. Focal Laser Ablation

FLA, or laser interstitial thermal therapy, uses laser-emitted light to induce tissue coagulation through direct heating, achieving irreversible tissue damage at temperatures above 60 °C. Like HIFU, TULSA, and cryotherapy, it is a thermal energy-based technique [27].
Unlike other focal treatments, FLA can be delivered transrectally or transperineally and often employs MRI guidance for precise targeting and real-time temperature monitoring. FLA can be performed under sedation, spinal anesthesia, or general anesthesia, with some studies exploring office-based transperineal FLA under local anesthesia using MRI-ultrasound fusion for guidance [31].
In the transperineal approach, a laser applicator system within a cooled catheter is inserted using an MRI-compatible trocar and template grid, while the transrectal approach involves a cooling catheter and laser fiber guided toward the lesion. Thermal probes may provide additional safety monitoring. Postoperative catheter use varies, but is recommended for large ablations or peri-urethral lesions to prevent urinary retention. FLA is typically performed as an outpatient procedure [31,32].

3.2.4. Irreversible Electroporation

IRE is a non-thermal technique using high-frequency electrical pulses (70–90 µs) to create permanent pores in cell membranes, leading to apoptosis through calcium ion influx. General anesthesia with complete muscle paralysis is essential to prevent severe muscle contractions or epileptic seizures caused by high-energy pulses. Due to the risk of arrhythmias, IRE is contraindicated in patients with epilepsy or cardiac arrhythmias [33,34].
In the lithotomy position, needle electrodes are placed transperineally around the lesion under transrectal ultrasound guidance, maintaining a maximum 2 cm distance between electrodes. After a 20-pulse trial, the current is assessed, and adjustments are made if needed before delivering the remaining 80 pulses. A catheter is typically removed 48 h post-procedure [35].

3.2.5. Focal Brachytherapy

Ionizing radiation induces cell death through mechanisms like apoptosis, necrosis, autophagy-dependent cell death, and immunogenic cell death. When radioactive material is placed inside the body, the process is called brachytherapy [36]. Focal brachytherapy includes two modalities: low-dose-rate (LDR) and high-dose-rate (HDR). LDR involves permanent radioactive seed implantation, while HDR uses temporary transperineal needles to deliver high-intensity radiation, offering precise dose control but requiring advanced equipment and shielded rooms [37].
New focal brachytherapy terms include focal-gross tumor volume (F-GTV), focal-clinical target volume (F-CTV), and focal-planning target volume (F-PTV), integrating margins to address imaging and delivery uncertainties. Performed under general or spinal anesthesia, the procedure uses imaging guidance to place radioactive seeds accurately, minimizing exposure to healthy tissues. Patients are typically discharged with a catheter for 2–5 days [38,39].

4. Lesion-Centric Technique Description: Shifting from Energy-Based to Lesion-Based Approaches

Not all surgeries are suited to robotic, laparoscopic, endourologic, or open techniques. Surgeons must carefully evaluate the patient and pathology to select the most appropriate approach, avoiding a “one-size-fits-all” strategy. In urology, this is evident in lithiasis cases, where diverse tools are needed to address calculi of varying composition, size, location, and patient-specific factors [40].
Similarly, in FT, no single energy source is universally effective or safe for all prostate lesions. Optimal outcomes require selecting the appropriate energy source and approach to target the lesion while protecting surrounding structures like the sphincter and rectum. This highlights the need for a versatile toolkit, tailoring the approach to the lesion rather than forcing the lesion to fit a specific tool. A lesion-focused strategy is essential for successful treatment [41].

4.1. Prostate Lesions Located in the Posterior Region

4.1.1. High-Intensity Focused Ultrasound for Posterior Lesions

HIFU is a good option for treating posterior lesions for two key reasons. First, its transrectal energy delivery allows precise targeting. Second, HIFU, along with cryotherapy, is among the most studied energy sources, with the strongest evidence base in FT [1]. Notably, while rectal fistula is a frequent concern, a study of over 1500 patients reported a low incidence (1.3%), comparable to the rates observed with radical prostatectomy and RT [42].

4.1.2. Transurethral Ultrasound Ablation for Posterior Lesions

Although no studies have directly compared outcomes using TULSA for different areas of treatment, this modality can be considered a suitable treatment option if the distal part of the treatment area (including the lesions and corresponding margins) is no more than 3 cm away, as this corresponds to the distal focal length of the device [11].

4.1.3. Cryotherapy for Posterior Lesions

Cryotherapy is generally not recommended for posterior lesions due to concerns about rectal damage or undertreatment. However, these risks remain hypothetical, as further research has not validated them [9].
On the other hand, studies on hemi-ablation and whole-gland ablation using cryotherapy have shown good oncological and functional outcomes with minimal side effects when performed by skilled surgeons. Common measures to conduct the procedure safely include urethral warming catheters, rectal heating devices, and thermocouple probes for temperature monitoring [43,44].
A systematic review of 16 studies (6 on cryotherapy, 10 on HIFU) reported similar recto-urethral fistula rates (0.8% for cryotherapy, 0.7% for HIFU). Thus, with experienced practitioners, cryotherapy may be a viable option for posterior lesions [43].
Furthermore, a recent retrospective study evaluating MRI fusion-targeted cryotherapy outcomes in 205 patients with anterior lesions, 56 with anterior-posterior lesions, and 553 with posterior lesions found no significant differences in five-year progression-free survival rates—87%, 89%, and 90% for anterior, anterior–posterior, and posterior lesions, respectively (p = 0.22). Additionally, functional outcomes were similar across groups, and no cases of rectal fistulas were reported [12].

4.1.4. Focal Laser Ablation for Posterior Lesions

FLA shows great versatility, being applicable both transrectally and transperineally. However, no studies have yet evaluated outcomes based on lesion location. Eric Walser et al. reported the largest FLA series to date with 120 patients, detailing the transrectal approach across four locations: anterior 16 (10.8%), central 8 (5.4%), transition 16 (10.8%), and peripheral 108 (73.0%). While location-specific results, especially for the apex or posterior part, were not recorded, two patients (1.6%) developed transrectal fistulas [32]. Thus, although FLA is not contraindicated for posterior lesions, evidence supporting its safety for peripheral lesions near the rectum remains limited, emphasizing the need for skilled operators.

4.1.5. Irreversible Electroporation for Posterior Lesions

Historically, transperineal treatments have been discouraged for posterior lesions. However, with careful evaluation of gland anatomy and maintaining a minimum 5 mm margin from critical structures like the rectum, IRE has proven to be a viable option for lesions in the posterior part of the gland. Scheltema et al. conducted a prospective study assessing genitourinary function and quality of life following IRE ablation across various prostate segments (anterior vs. posterior, apex vs. base, apex-to-base, unilateral vs. bilateral). Among 60 patients, the study found no statistically significant differences in outcomes between segments, concluding that IRE can be safely performed on all prostate regions. Thus, with expertise and a comprehensive understanding of transperineal biopsy and focal treatment—particularly the complexities of posterior lesions—IRE may be considered a safe option for managing such cases [10].

4.1.6. Focal Brachytherapy for Posterior Lesions

Most brachytherapy studies focus on the apex–base lesion location, as proximity to the base and bladder neck is associated with poorer functional outcomes. Despite limited series, some authors report favorable outcomes for posterior lesions, with the use of rectal spacers potentially reducing rectal symptoms after focal treatment [36].

4.2. Prostate Lesions Located in the Anterior Region

4.2.1. High-Intensity Focused Ultrasound for Anterior Lesions

Ultrasound waves can treat lesions up to 3–4 cm from the treatment site, requiring the distal lesion to be within 4–5 cm of the probe for effective margins. While transrectal HIFU may theoretically treat anterior lesions in small prostates, a retrospective study found higher retreatment rates for anterior lesions compared to posterior ones (37.8% vs. 20.3%) in similar prostate volumes, likely due to energy loss across tissue planes and additive energy deposition in posterior tissue. Therefore, although not fully contraindicated, transrectal HIFU is less effective for anterior lesions, and other modalities may be more suitable [45].

4.2.2. Transurethral Ultrasound Ablation for Anterior Lesions

The TULSA device, with its transurethral positioning and 360-degree robotic treatment range of ~3 cm, is well suited for anterior lesions that transrectal HIFU may struggle to access. However, its effectiveness depends on appropriate patient selection, considering factors such as the presence of calcification [11].

4.2.3. Cryotherapy for Anterior Lesions

As one of the pioneering modalities in FT, cryotherapy has amassed a considerable body of scientific evidence, like HIFU, though with varying quality across studies. Currently, cryotherapy is regarded as an excellent treatment option for anteriorly located lesions, offering favorable oncological and functional outcomes [1].

4.2.4. Focal Laser Ablation for Anterior Lesions

FLA, especially in its transperineal version, like any other energy delivered transperineally, represents a very good treatment choice for anterior lesions [46].

4.2.5. Irreversible Electroporation for Anterior Lesions

Anterior lesions are easily accessible with transperineal needle-based energies, making IRE a suitable option for their treatment [10].

4.3. Prostate Lesion Located in the Apex

Treating the apex is one of the most challenging areas, regardless of energy modality. Positive apical margins after prostatectomy can reach 27%, a significant predictor of BCR, and RT recurrence often involves the apical region [47,48].
When treating apical lesions, the first consideration is the definition and anatomical boundaries of the prostatic apex, often described as the gland’s narrowest part above the urogenital diaphragm and near the elevator ani muscles. MRI limits are not definitive, so lesions labeled apical should be carefully evaluated, as some may be distant from the sphincter and suitable for focal treatment [49].

4.3.1. High-Intensity Focused Ultrasound for Apical Lesions

Apical lesions can be treated safely with a minimum 5–10 mm margin from the sphincter. However, not all lesions are small or prostates large enough to maintain these margins, making suitable candidates for apical treatment relatively rare [50].

4.3.2. Transurethral Ultrasound Ablation for Apical Lesions

Currently, evidence is lacking to confirm the efficacy of TULSA for apical lesions or the impact of MRI monitoring on outcomes. Until further studies clarify its applications, careful evaluation is essential before considering ultrasound-based thermal treatment for apical lesions [11].

4.3.3. Cryotherapy for Apical Lesions

Cryotherapy for apex lesions may be suitable in specific cases where sphincter safety margins are maintained, particularly in reputable centers. While retrospective studies suggest oncological effectiveness, functional outcomes remain underexplored [50].

4.3.4. Focal Laser Ablation for Apical Lesions

FLA should generally be avoided for apical lesions due to challenges in controlling treatment limits. While MRI monitoring may improve energy delivery accuracy, no evidence currently supports its safe use at the apex [32].

4.3.5. Irreversible Electroporation for Apical Lesions

IRE has been tested for apical lesions. In Scheltema et al.’s study, 18 patients treated at the apex showed no differences in genitourinary function or quality of life compared to other regions [10]. Blazevski et al. treated 50 patients with lesions near the apical capsule, reporting no severe complications (Clavien-Dindo ≥ 3) and no significant changes in urinary or bowel quality of life after 12 months. Among the initially potent patients, 94% remained potent, with only one requiring a pad for incontinence. Post-treatment biopsies revealed one in-field recurrence among 80% of the patients [51]. These findings suggest that IRE can be safely used for apical lesions, though more robust oncological data are needed.

4.3.6. Focal Brachytherapy for Apical Lesions

Retrospective studies indicate that focal brachytherapy at the prostate apex results in less urinary toxicity than at the base, with no significant impact on erectile function. However, limited series, short follow-ups, and less favorable oncological outcomes suggest that brachytherapy is not clearly superior for apical lesions compared to other modalities [36].

5. Limitations of the Study

Most of the studies included in this review are retrospective, involving heterogeneous populations and variable outcomes. In addition, long-term outcomes remain insufficiently reported. Furthermore, studies examining outcomes based on lesion location and those comparing different energy sources are limited, making it challenging to draw definitive conclusions regarding the optimal technique for each lesion. Finally, as a non-systematic review, this study did not follow a strict, predefined protocol for study selection, which may introduce selection bias and limit reproducibility.

6. Conclusions

In conclusion, FT, as a highly technology-dependent treatment modality, evolves rapidly, encompassing patient selection, treatment execution, and follow-up. Regarding treatment, no single energy modality is universally suitable for all cases, nor is any one energy modality confined to a specific location. Instead, selecting the most appropriate technique based on disease characteristics, tool availability, surgeon expertise, and patient preferences represents the most practical strategy.

Author Contributions

L.R.-S., T.J.P., P.K.-F.C., M.E., B.E., H.U.A., A.A., A.R.R., K.W. and R.S.-S. have made substantial contributions to the design of the work and the acquisition, analysis, or interpretation of the studies reviewed, or has been involved in drafting or substantively revising the manuscript. Additionally, each author has approved the submitted version and agrees to be personally accountable for their own contributions. Each author also accepts responsibility for addressing questions regarding the accuracy or integrity of any part of the work, ensuring that any concerns are thoroughly investigated, resolved, and documented in the literature, even for areas where they were not directly involved. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Acknowledgments

We would like to express our sincere gratitude to Scott Eggener, Mack Roach III, and Laurence Klotz for the opportunity to contribute to the remarkable project of the 3rd WUOF/SIU International Consultation on Urological Diseases (ICUD) on Localized PCa. We are especially thankful for the inclusion of a chapter dedicated to explaining the practical approaches to performing FT, allowing us to share insights and advancements in this specialized field.

Conflicts of Interest

Lara Rodriguez-Sanchez is involved in consulting and speaking engagements for AngioDynamics. Additionally, she received speaker fees from EDAP-TMS. J Polascik is involved in studies supported by Janssen Bladder Cancer, Myovant Sciences, Prostatype Genomics, Merck, Astellas mCSPC, and Astellas mHSPC. Ardeshir R. Rastinehad declares consulting and research support from Philips Healthcare (Best, Netherlands) and Nanospectra Biosciences (Houston, TX, USA). Peter Ka-Fung Chiu receives research support from the General Research Fund (GRF) and the Health and Medical Research Fund (HMRF) in Hong Kong, China. Kara Watts serves as a consultant and speaker for Sonablate. Mark Emberton has roles as a speaker, advisor, consultant, and trainer for Sonacare Inc., AngioDynamics, NINA Medical, and Albermarle Medical; he is also a shareholder and consultant for Early Health Ltd. Hashim U. Ahmed receives infrastructure support from the NIHR Imperial Biomedical Research Centre and Imperial College Experimental Cancer Medicine Centre, as well as core funding from the UK NIHR Imperial Biomedical Research Centre (BRC), the Wellcome Trust, the UK NIHR, the UK Medical Research Council, Cancer Research UK, Prostate Cancer UK, the Urology Foundation, the British Medical Association Foundation, Imperial Health Charity, Sonablate, Trod Medical, and Sophiris Biocorp. He has received travel allowance from Sonablate and was a paid consultant for Sophiris Biocorp. He has received sponsorship from Angiodynamics for conference attendance and has been on the medical advisory board for Janssen for the last 3 years. Additionally, he is a proctor for Rezum treatment and cryotherapy for Boston Scientific and a paid proctor for HIFU by Sonablate. André Abreu serves as a proctor and participates in research trials with Koelis. He is also a proctor and speaker for Sonablate and a speaker for EDAP. Rafael Sanchez-Salas declares serving as a speaker and consultant for Abbvie Canada, EDAP-TMS, ExactImaging, and Angiodynamics, with the Angiodynamics involvement also noting a spousal relationship. Additionally, he declares serving as a speaker for Janssen Canada, Tolmar Canada, and TerSera Canada. Behfar Ehdaie has no conflicts of interest to disclose.

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Siuj 06 00038 g001
Figure 1. Representation of the different approaches for focal therapy in prostate cancer. Green: transrectal approach; violet: transperineal approach; red: transurethral approach. The red arrow shows that the transurethral device can rotate a full 360 degrees, allowing it to complete a complete rotation around its axis. From Société Internationale d’Urologie (SIU) & World Urologic Oncology Federation (WUOF), Localized Prostate Cancer Treatment Strategies, 2023, pp. 497–525).
Figure 1. Representation of the different approaches for focal therapy in prostate cancer. Green: transrectal approach; violet: transperineal approach; red: transurethral approach. The red arrow shows that the transurethral device can rotate a full 360 degrees, allowing it to complete a complete rotation around its axis. From Société Internationale d’Urologie (SIU) & World Urologic Oncology Federation (WUOF), Localized Prostate Cancer Treatment Strategies, 2023, pp. 497–525).
Siuj 06 00038 g001
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Figure 2. Standard 2-block approach (a) vs. dose escalation using 3 blocks (b) of treatment layered approach to focal high-intensity focused ultrasound (HIFU) with Sonablate 500. Each colored rectangle represents a different treatment block. From Société Internationale d’Urologie (SIU) & World Urologic Oncology Federation (WUOF), Localized Prostate Cancer Treatment Strategies, 2023, pp. 497–525).
Figure 2. Standard 2-block approach (a) vs. dose escalation using 3 blocks (b) of treatment layered approach to focal high-intensity focused ultrasound (HIFU) with Sonablate 500. Each colored rectangle represents a different treatment block. From Société Internationale d’Urologie (SIU) & World Urologic Oncology Federation (WUOF), Localized Prostate Cancer Treatment Strategies, 2023, pp. 497–525).
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Table 1. Comparison of main energy-based prostate treatments.
Table 1. Comparison of main energy-based prostate treatments.
Treatment ModalityEnergyType of Energy SourceRoute of
Application
High-Intensity Focused Ultrasound (HIFU)Ultrasound wavesThermal (60 to 90 °C)Transrectal
MRI-Guided Transurethral Ultrasound Ablation (TULSA)Ultrasound wavesThermal (60 to 90 °C)Transurethral
CryotherapyIce ball–extreme cold temperaturesThermal (−40 °C)Transperineal
Focal Laser Ablation (FLA)Laser energyThermal (>60 °C)Transperineal or Transrectal
Irreversible Electroporation (IRE)Electrical pulses Non-thermalTransperineal
Focal BrachytherapyIonizing radiationNon-thermalTransperineal
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Rodriguez-Sanchez, L.; Polascik, T.J.; Watts, K.; Chiu, P.K.-F.; Emberton, M.; Ehdaie, B.; Ahmed, H.U.; Abreu, A.; Rastinehad, A.R.; Sanchez-Salas, R. SIU-ICUD Focal Therapy for PCa: The Technique. Soc. Int. Urol. J. 2025, 6, 38. https://doi.org/10.3390/siuj6030038

AMA Style

Rodriguez-Sanchez L, Polascik TJ, Watts K, Chiu PK-F, Emberton M, Ehdaie B, Ahmed HU, Abreu A, Rastinehad AR, Sanchez-Salas R. SIU-ICUD Focal Therapy for PCa: The Technique. Société Internationale d’Urologie Journal. 2025; 6(3):38. https://doi.org/10.3390/siuj6030038

Chicago/Turabian Style

Rodriguez-Sanchez, Lara, Thomas J. Polascik, Kara Watts, Peter Ka-Fung Chiu, Mark Emberton, Behfar Ehdaie, Hashim U. Ahmed, Andre Abreu, Ardeshir R. Rastinehad, and Rafael Sanchez-Salas. 2025. "SIU-ICUD Focal Therapy for PCa: The Technique" Société Internationale d’Urologie Journal 6, no. 3: 38. https://doi.org/10.3390/siuj6030038

APA Style

Rodriguez-Sanchez, L., Polascik, T. J., Watts, K., Chiu, P. K.-F., Emberton, M., Ehdaie, B., Ahmed, H. U., Abreu, A., Rastinehad, A. R., & Sanchez-Salas, R. (2025). SIU-ICUD Focal Therapy for PCa: The Technique. Société Internationale d’Urologie Journal, 6(3), 38. https://doi.org/10.3390/siuj6030038

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