Focal therapy for prostate cancer aims to provide adequate oncological control for prostate cancer while minimizing treatment-related morbidity associated with conventional whole-gland treatments, including radical prostatectomy and radiation therapy. Focal therapy limits treatment to only the portion of prostate containing the clinically significant prostate cancer along with margin, thereby preserving the remainder of the gland and, importantly, the surrounding structures. By doing so, treatment-related functional morbidity can be reduced greatly.

Perhaps the biggest concern for men undergoing prostate cancer treatment is the possibility of incontinence. A meta-analysis demonstrated incontinence rates of 4% to 31%, with a mean value of 16% after robot-assisted radical prostatectomy.¹ Novel techniques, such as the Retzius sparing approach, have improved early continence outcomes, but long-term continence rates remain similar.² Radiation therapy also can have profound effects on urinary function. Aside from the long-term risk of incontinence, patients may develop bothersome irritative and obstructive voiding symptoms during and following treatment. Furthermore, some patients develop debilitating chronic conditions, such as radiation cystitis or proctitis, which can have an impact on the quality of life even years after radiation therapy. Conversely, focal therapy approaches have shown very low rates of incontinence compared with conventional treatments. Cryotherapy, high-intensity–focused ultrasound (HIFU), and irreversible electroporation (IRE) are three popular ablation technologies currently used in focal therapy. A recent systematic review showed that 98% of patients were fully continent 6 months after focal HIFU.³ In another systematic review, continence rates were 95.1% to 100% by 3-12 months after focal cryotherapy.⁴ Additionally, urinary continence was preserved in 99% of patients undergoing focal IRE.⁵

Sexual dysfunction is another common adverse effect of prostate cancer treatment. Sexual function is affected greatly by radical prostatectomy. By the very nature of the procedure, the loss of ejaculation is guaranteed, and a meta-analysis showed 12-month erectile dysfunction rates ranging from 10% to 46%.⁶ Radiation therapy may have lower rates of early erectile dysfunction, but the long-term patients undergoing either conventional treatment have similar rates of sexual dysfunction.⁷ Additionally, some patients undergoing radiation therapy will require androgen deprivation therapy, further predisposing them to sexual dysfunction, including erectile dysfunction, decreased sexual desire, orgasmic dysfunction, ejaculatory dysfunction, and testicular atrophy. On the other hand, focal therapy offers excellent preservation of sexual function. In a meta-analysis, 80% of patients retained sufficient erections for sexual intercourse after focal HIFU.³ Shah et al showed that 83.8% of patients maintained erections sufficient for penetration after focal cryotherapy.⁸ Following focal IRE, erections sufficient for intercourse decreased by only 13% compared with baseline.⁵ In addition to maintaining erectile dysfunction, some patients were even able to maintain ejaculatory function after focal therapy. Focal therapy also allows for avoidance of androgen deprivation therapy.

In summary, conventional whole-gland treatments for prostate cancer, including radical prostatectomy and radiation therapy, are associated with substantial morbidity of urinary and sexual function. Focal therapy offers an alternative strategy that provides a considerable reduction in the rates of incontinence and erectile dysfunction. Early and medium-term oncological data have been promising with focal therapy.⁹ Although long-term oncological data are still needed, focal therapy appears to provide reasonable oncological control and superior functional outcomes. It has been shown that the patients with prostate cancer are willing to accept some degree of reduced oncological control for improvements in quality of life after treatment.¹⁰ Therefore, even as we await long-term data, focal therapy with its superior functional outcomes offers an alternative option for patients and a middle ground to those seeking prostate cancer treatment but in whom the morbidity of conventional treatments is unacceptable.